Healthcare Provider Details

I. General information

NPI: 1225311921
Provider Name (Legal Business Name): TIFFANY M GREENE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY M FAUST PA-C

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8423 MARKET ST STE 205
BOARDMAN OH
44512-6778
US

IV. Provider business mailing address

8423 MARKET ST STE 205
BOARDMAN OH
44512-6778
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-5490
  • Fax: 330-965-5491
Mailing address:
  • Phone: 330-965-5490
  • Fax: 330-965-5491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number50003400
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.003400RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: