Healthcare Provider Details

I. General information

NPI: 1619386570
Provider Name (Legal Business Name): MAGDALENA TIBETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MONTAUK HWY SUITE 3-1
WEST ISLIP NY
11795-4910
US

IV. Provider business mailing address

1111 MONTAUK HIGHWAY SUITE 3-1
WEST ISLIP NY
11795-4910
US

V. Phone/Fax

Practice location:
  • Phone: 631-669-1171
  • Fax:
Mailing address:
  • Phone: 631-669-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017830
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: