Basic Information
| Provider Information | |||||||||
| NPI: | 1265721245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOGLIA | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OLIVA | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 46 FELLSMERE ST | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019042018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814628556 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 UNICORN PARK DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018013324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817821300 | ||||||||
| FaxNumber: | 7817821350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2011 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA4108 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.