Healthcare Provider Details

I. General information

NPI: 1275672503
Provider Name (Legal Business Name): KEVIN TIYAAMORNWONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E ALMOND AVE STE 101
MADERA CA
93637-5745
US

IV. Provider business mailing address

344 E 6TH ST
MADERA CA
93638-3631
US

V. Phone/Fax

Practice location:
  • Phone: 559-664-4000
  • Fax: 559-675-5224
Mailing address:
  • Phone: 559-664-4000
  • Fax: 559-675-5224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 17984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: