MEDICARE: TYRA CHANE'L JONES-WIGGINS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant		CA

General Provider Information

NPI Number	:	1346183050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA CHANE'L JONES-WIGGINS

Provider Business Mailing Address
First Line	:	1160 E AVENUE J6
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93535-4401
Country	:	US
Telephone Number	:	661-236-3960
Fax Number	:	661-236-3960

Provider Business Practice Location Address
First Line	:	1160 E AVENUE J6
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93535-4401
Country	:	US
Telephone Number	:	661-236-3960
Fax Number	:	661-236-3960

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2026
Last Update Date	:	04/09/2026

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