Provider Demographics
NPI:1912943143
Name:SELBERG, TONYA TIFFANY (PA-C)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:TIFFANY
Last Name:SELBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:TONYA
Other - Middle Name:TIFFANY
Other - Last Name:VAN SANTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:275 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4531
Mailing Address - Country:US
Mailing Address - Phone:707-462-7900
Mailing Address - Fax:707-462-7947
Practice Address - Street 1:275 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4531
Practice Address - Country:US
Practice Address - Phone:707-462-7900
Practice Address - Fax:707-462-7947
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ09492Medicare UPIN
CA0PA172341Medicare ID - Type Unspecified