Provider Demographics
NPI:1720441355
Name:KEITH, TIFFANY EDWARDS (MHS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:EDWARDS
Last Name:KEITH
Suffix:
Gender:F
Credentials:MHS, PA-C
Other - Prefix:MISS
Other - First Name:TIFFANY
Other - Middle Name:BROOKE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-399-6169
Mailing Address - Fax:
Practice Address - Street 1:1220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4355
Practice Address - Country:US
Practice Address - Phone:601-426-4000
Practice Address - Fax:601-426-4105
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058228363AM0700X
MSPA00374363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical