=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912473182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY MICHELLE JANES PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2018
-----------------------------------------------------
Last Update Date | 09/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4338 W THOMAS RD STE 173
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85031-3878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-429-2239
-----------------------------------------------------
Fax | 602-559-5436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4338 W THOMAS RD STE 173
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85031-3878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-570-6964
-----------------------------------------------------
Fax | 480-559-5436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 7591
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------