Provider Demographics
NPI:1548640873
Name:POLO, TIFFANY E
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:E
Last Name:POLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 SHARON RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:KING WILLIAM
Mailing Address - State:VA
Mailing Address - Zip Code:23086-3347
Mailing Address - Country:US
Mailing Address - Phone:804-746-1677
Mailing Address - Fax:804-769-3170
Practice Address - Street 1:1041 SHARON RD
Practice Address - Street 2:SUITE 205
Practice Address - City:KING WILLIAM
Practice Address - State:VA
Practice Address - Zip Code:23086-3347
Practice Address - Country:US
Practice Address - Phone:804-746-1677
Practice Address - Fax:804-769-3170
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172717363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05698OtherGROUP PTAN