Healthcare Provider Details

I. General information

NPI: 1992249163
Provider Name (Legal Business Name): TIFFANY GALICIA BEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

385 W MAIN ST
AVON CT
06001-4357
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-0711
  • Fax:
Mailing address:
  • Phone: 203-688-1734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4711
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number54060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: