Healthcare Provider Details

I. General information

NPI: 1275257776
Provider Name (Legal Business Name): CONOR WILLIAM TIBBS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CAMINO DEL RIO N STE 805
SAN DIEGO CA
92108-1546
US

IV. Provider business mailing address

6221 METROPOLITAN ST STE 201
CARLSBAD CA
92009-3096
US

V. Phone/Fax

Practice location:
  • Phone: 760-753-7127
  • Fax: 760-334-0399
Mailing address:
  • Phone: 760-753-7127
  • Fax: 760-334-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number63761
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: