MEDICARE: MRS. TIFFANY ELISE HEESE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA60637513	WA
2	363A00000X	Physician Assistant
3	363AM0700X	Medical Physician Assistant	PA60637513	WA
4	363A00000X	Physician Assistant	PA12294	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	G001045700	OTHER	WA	GROUP PTAN(P)

General Provider Information

NPI Number	:	1972960250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANY ELISE HEESE PA-C

Provider Business Mailing Address
First Line	:	19284 STONE OAK PKWY STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3474
Country	:	US
Telephone Number	:	210-268-1024
Fax Number	:	210-268-0141

Provider Business Practice Location Address
First Line	:	19284 STONE OAK PKWY STE 102
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-3474
Country	:	US
Telephone Number	:	210-268-0124
Fax Number	:	210-268-0141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2016
Last Update Date	:	01/17/2019

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