Provider Demographics
NPI:1336797117
Name:TAYLOR, TIFFANY DAWN (MPA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DAWN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:DAWN
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPA
Mailing Address - Street 1:PO BOX 10700
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-5517
Mailing Address - Country:US
Mailing Address - Phone:970-254-2642
Mailing Address - Fax:
Practice Address - Street 1:3150 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-2863
Practice Address - Country:US
Practice Address - Phone:970-256-5201
Practice Address - Fax:970-256-5202
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-26
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant