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General NPI Number Information
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NPI Number | 1386896595
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Entity Type | Individual
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Provider Name | TIFFANY JO ARCHER PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/21/2008
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Last Update Date | 11/07/2024
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Provider Practice Location Address
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Address Line | 5501 MARVIN SHIELDS BLVD
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City | GULFPORT
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State | MS
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Zip | 39501-9007
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Country | US
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Telephone | 228-871-4033
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Fax | 228-871-3344
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Provider Business Mailing Address
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Address Line | 5016 EAGLE DR
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City | GULFPORT
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State | MS
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Zip | 39501-3702
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Country | US
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Telephone | 785-215-1664
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 15-01691
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 19896
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License Number State | CA
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