Healthcare Provider Details

I. General information

NPI: 1982911012
Provider Name (Legal Business Name): TIFFANY KATULS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5857 PINE AVE
CHINO HILLS CA
91709-6536
US

IV. Provider business mailing address

5393 STONEVIEW RD
RANCHO CUCAMONGA CA
91739-8931
US

V. Phone/Fax

Practice location:
  • Phone: 909-287-7474
  • Fax:
Mailing address:
  • Phone: 909-648-3928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21100
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: