Healthcare Provider Details

I. General information

NPI: 1184652695
Provider Name (Legal Business Name): TIFFANY WATERS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY BENNING P.A.

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 SHADELANDS DR
WALNUT CREEK CA
94598-2444
US

IV. Provider business mailing address

PO BOX 31396
WALNUT CREEK CA
94598-8396
US

V. Phone/Fax

Practice location:
  • Phone: 925-939-8585
  • Fax: 925-933-2709
Mailing address:
  • Phone: 925-939-8585
  • Fax: 925-933-2709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA17246
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17246
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: