Healthcare Provider Details

I. General information

NPI: 1770766123
Provider Name (Legal Business Name): TIFFANY LYNN EKNO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 W 34TH ST SUITE 100
AUSTIN TX
78703-1400
US

IV. Provider business mailing address

1510 W 34TH ST SUITE 100
AUSTIN TX
78703-1400
US

V. Phone/Fax

Practice location:
  • Phone: 512-533-9900
  • Fax: 512-533-9901
Mailing address:
  • Phone: 512-533-9900
  • Fax: 512-533-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA07014
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: