Provider Demographics
NPI:1770804387
Name:SHOWALTER, TIFFANI D (PA)
Entity type:Individual
Prefix:MISS
First Name:TIFFANI
Middle Name:D
Last Name:SHOWALTER
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 309
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0309
Mailing Address - Country:US
Mailing Address - Phone:701-766-1600
Mailing Address - Fax:
Practice Address - Street 1:3883 74TH AVENUE NE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06531363AM0700X
AK964363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical