Provider Demographics
NPI:1811681687
Name:LUONG, TIFFANY GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:GRACE
Last Name:LUONG
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 1:3325 E CHARLINDA ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-3004
Mailing Address - Country:US
Mailing Address - Phone:626-675-3799
Mailing Address - Fax:
Practice Address - Street 1:1202 E GREEN ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-3112
Practice Address - Country:US
Practice Address - Phone:626-576-1800
Practice Address - Fax:626-576-1808
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant