Healthcare Provider Details

I. General information

NPI: 1598802480
Provider Name (Legal Business Name): TIFFANI DIANE BURGIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 MEDICAL DR
SAN ANTONIO TX
78229
US

IV. Provider business mailing address

7703 FLOYD CURL DR # MC7977
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-9144
  • Fax: 210-358-8536
Mailing address:
  • Phone: 210-450-9180
  • Fax: 210-450-2117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04883
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: