Healthcare Provider Details

I. General information

NPI: 1144581554
Provider Name (Legal Business Name): TIFFANY CARLSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MISSION RANCH BLVD STE 10
CHICO CA
95926-5137
US

IV. Provider business mailing address

114 MISSION RANCH BLVD STE 10
CHICO CA
95926-5137
US

V. Phone/Fax

Practice location:
  • Phone: 530-894-0500
  • Fax:
Mailing address:
  • Phone: 530-894-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A13006
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: