Healthcare Provider Details

I. General information

NPI: 1760909535
Provider Name (Legal Business Name): TIA LYNN FOX PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PAVILION WAY
SOUTHERN PINES NC
28387-4561
US

IV. Provider business mailing address

200 PAVILION WAY
SOUTHERN PINES NC
28387-4561
US

V. Phone/Fax

Practice location:
  • Phone: 910-235-3330
  • Fax:
Mailing address:
  • Phone: 910-235-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberPA9110439
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number001011773
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11773
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: