Provider Demographics
NPI:1770903056
Name:CAZA, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:CAZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:NICOLE
Other - Last Name:TELARICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10810 EXECUTIVE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4386
Mailing Address - Country:US
Mailing Address - Phone:501-604-2695
Mailing Address - Fax:
Practice Address - Street 1:10810 EXECUTIVE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211
Practice Address - Country:US
Practice Address - Phone:501-604-2695
Practice Address - Fax:501-604-2699
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
ARE11011207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No291U00000XLaboratoriesClinical Medical Laboratory