Healthcare Provider Details

I. General information

NPI: 1467838664
Provider Name (Legal Business Name): JACLYN ELISE TYBOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 S UNION BLVD STE 800
LAKEWOOD CO
80228-2213
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 303-988-2680
  • Fax:
Mailing address:
  • Phone: 303-763-4900
  • Fax: 303-763-5495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0004315
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: