MEDICARE: TIFFANY KIDD WORMUTH PA

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	NJDCATEMP-007343	NJ
2	363A00000X	Physician Assistant	0110001946	VA

General Provider Information

NPI Number	:	1992727416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY KIDD WORMUTH PA

Provider Business Mailing Address
First Line	:	1300 SENTARA PARK # 3
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5884
Country	:	US
Telephone Number	:	757-252-3050
Fax Number	:

Provider Business Practice Location Address
First Line	:	6512 WOODLAKE VILLAGE CIR
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23112-2200
Country	:	US
Telephone Number	:	888-628-8272
Fax Number	:

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	12/16/2025

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