Provider Demographics
NPI:1649462342
Name:TIFFANY, RACHELLE (PA)
Entity type:Individual
Prefix:MRS
First Name:RACHELLE
Middle Name:
Last Name:TIFFANY
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:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:316-689-9769
Practice Address - Street 1:1947 N FOUNDERS CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206
Practice Address - Country:US
Practice Address - Phone:316-613-4680
Practice Address - Fax:316-613-4906
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2011-0035363A00000X
KS15-01203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96088834Medicaid
NM96088834Medicaid