Provider Demographics
NPI:1861797060
Name:KORRER, TIFFANY MARIE (PTA)
Entity type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:MARIE
Last Name:KORRER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 516
Mailing Address - Street 2:
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851
Mailing Address - Country:US
Mailing Address - Phone:208-686-7041
Mailing Address - Fax:208-686-5712
Practice Address - Street 1:1100 A. STREET
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-7041
Practice Address - Fax:208-686-5712
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-2740225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807854400Medicaid
ID807854400Medicaid