Healthcare Provider Details

I. General information

NPI: 1457819815
Provider Name (Legal Business Name): TIFFANY TIRTADINATA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3594
US

IV. Provider business mailing address

156 SERRA LN
DALY CITY CA
94015-2782
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-8000
  • Fax:
Mailing address:
  • Phone: 650-515-5709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002874
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: