Healthcare Provider Details

I. General information

NPI: 1265053680
Provider Name (Legal Business Name): TIFFANI IRENE POPP PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANI IRENE CASTELLI PA-C

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 BROADWAY ST
CAPE GIRARDEAU MO
63701-4553
US

IV. Provider business mailing address

1834 BROADWAY ST
CAPE GIRARDEAU MO
63701-4553
US

V. Phone/Fax

Practice location:
  • Phone: 832-869-4818
  • Fax: 832-869-4818
Mailing address:
  • Phone: 832-869-4818
  • Fax: 832-869-4853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2021034612
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: