Healthcare Provider Details

I. General information

NPI: 1386896595
Provider Name (Legal Business Name): TIFFANY JO ARCHER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 MARVIN SHIELDS BLVD
GULFPORT MS
39501-9007
US

IV. Provider business mailing address

5016 EAGLE DR
GULFPORT MS
39501-3702
US

V. Phone/Fax

Practice location:
  • Phone: 228-871-4033
  • Fax: 228-871-3344
Mailing address:
  • Phone: 785-215-1664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number19896
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number15-01691
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: