Healthcare Provider Details

I. General information

NPI: 1801281670
Provider Name (Legal Business Name): ELIZABETH TIBBS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH HAZLEHURST PA-C

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 N MERIDIAN ST STE 105
INDIANAPOLIS IN
46290
US

IV. Provider business mailing address

10590 N MERIDIAN ST # 105
CARMEL IN
46290-1028
US

V. Phone/Fax

Practice location:
  • Phone: 317-583-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11481
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1038
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002453A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10002453A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: