Basic Information
| Provider Information | |||||||||
| NPI: | 1780007104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAXEY | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 DE MOSS ST | ||||||||
| Address2: | HIDALGO MEDICAL SERVICES | ||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880452618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755422368 | ||||||||
| FaxNumber: | 5755422388 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 W 11TH ST | ||||||||
| Address2: | HMS MED SQUARE | ||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880615124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753881511 | ||||||||
| FaxNumber: | 5755422388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2014 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2014-0001 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA2014-0001 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 96120321 | 05 | NM | MEDICAID | 332530YKWY | 01 | NM | MEDICARE PTAN | OTHER |