1376552307 NPI number — TIFFANI MASAR PA

Table of content: TIFFANI MASAR PA (NPI 1376552307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376552307 NPI number — TIFFANI MASAR PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASAR
Provider First Name:
TIFFANI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376552307
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12395 NE 51ST TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34484-9610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-646-7501
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10250 SE 167TH PLACE RD UNIT 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERFIELD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34491-8682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-307-9925
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9113536 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108745600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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