Provider Demographics
NPI:1780007104
Name:MAXEY, TIFFANY (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MAXEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS ST
Mailing Address - Street 2:HIDALGO MEDICAL SERVICES
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2618
Mailing Address - Country:US
Mailing Address - Phone:575-542-2368
Mailing Address - Fax:575-542-2388
Practice Address - Street 1:114 W 11TH ST
Practice Address - Street 2:HMS MED SQUARE
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5124
Practice Address - Country:US
Practice Address - Phone:575-388-1511
Practice Address - Fax:575-542-2388
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMPA2014-0001363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96120321Medicaid
NM332530YKWYOtherMEDICARE PTAN