Provider Demographics
NPI:1356359095
Name:BARTELD, TIFFANY L (PA)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:L
Last Name:BARTELD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:L
Other - Last Name:MOLINARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3409 LUDINGTON STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829
Mailing Address - Country:US
Mailing Address - Phone:906-789-4427
Mailing Address - Fax:906-789-4446
Practice Address - Street 1:3409 LUDINGTON STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829
Practice Address - Country:US
Practice Address - Phone:906-789-4427
Practice Address - Fax:906-789-4446
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1356359095Medicaid