=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700877057
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY D WILSON M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 12/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 CREEK RD BLDG A STE 140
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92604-4724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-559-4480
-----------------------------------------------------
Fax | 949-262-7072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1744
-----------------------------------------------------
City | SUISUN CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94585-4744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 657-241-3600
-----------------------------------------------------
Fax | 657-241-7708
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A70066
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------