Basic Information
| Provider Information | |||||||||
| NPI: | 1578237442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAGE | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP -C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAGON | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542547211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 706 AVENUE G | ||||||||
| Address2: | |||||||||
| City: | MARBLE FALLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786545866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302018900 | ||||||||
| FaxNumber: | 8302018990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 09/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 1045567 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.