Healthcare Provider Details

I. General information

NPI: 1538494232
Provider Name (Legal Business Name): BRADLEY CHARLES TIBBETTS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 10/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HQ BAACH USAMEDDAC KOREA UNIT # 15244
APO AP
96205-5244
US

IV. Provider business mailing address

HHB, 6-37 FA
APO AP
96224
US

V. Phone/Fax

Practice location:
  • Phone: 01031054639
  • Fax:
Mailing address:
  • Phone: 01031054639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: