Provider Demographics
NPI:1295705085
Name:GATES-MABY, TIFFANY J (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:J
Last Name:GATES-MABY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-467-4195
Mailing Address - Fax:607-467-4194
Practice Address - Street 1:53 PINE ST
Practice Address - Street 2:
Practice Address - City:DEPOSIT
Practice Address - State:NY
Practice Address - Zip Code:13754-1301
Practice Address - Country:US
Practice Address - Phone:607-467-4195
Practice Address - Fax:607-467-6219
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002555L363A00000X
NY008098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03156636Medicaid
S47237Medicare UPIN
NY03156636Medicaid