Healthcare Provider Details

I. General information

NPI: 1720862634
Provider Name (Legal Business Name): COLLIN SCOTT TIBBITTS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41274 N CAMBRIA DR
SAN TAN VALLEY AZ
85140-3173
US

IV. Provider business mailing address

41274 N CAMBRIA DR
SAN TAN VALLEY AZ
85140-3173
US

V. Phone/Fax

Practice location:
  • Phone: 801-436-4517
  • Fax:
Mailing address:
  • Phone: 801-436-4517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number249773
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: