Provider Demographics
NPI:1750557062
Name:BAILEY, TIFFANY NICOLE (PA)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:NICOLE
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:NICOLE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7626
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7626
Mailing Address - Country:US
Mailing Address - Phone:270-443-2900
Mailing Address - Fax:270-443-7122
Practice Address - Street 1:2603 KENTUCKY AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3814
Practice Address - Country:US
Practice Address - Phone:270-443-2900
Practice Address - Fax:270-443-7122
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1127363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0933406Medicare PIN