Healthcare Provider Details

I. General information

NPI: 1902586225
Provider Name (Legal Business Name): JOSHUA P TIBBELS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 NORTH ST STE A
HYANNIS MA
02601-3825
US

IV. Provider business mailing address

130 NORTH ST STE A
HYANNIS MA
02601-3825
US

V. Phone/Fax

Practice location:
  • Phone: 508-568-3761
  • Fax: 508-775-8280
Mailing address:
  • Phone: 508-775-8282
  • Fax: 508-775-8280

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: