Provider Demographics
NPI:1871787457
Name:HIATT, TIFFANY L (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:HIATT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LEANN
Other - Last Name:BEAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:11304 HAWTHORNE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9302
Mailing Address - Country:US
Mailing Address - Phone:704-384-8760
Mailing Address - Fax:704-384-8783
Practice Address - Street 1:11304 HAWTHORNE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-9302
Practice Address - Country:US
Practice Address - Phone:704-384-8760
Practice Address - Fax:704-384-8783
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
2759093Medicare PIN
NC2759093Medicare PIN