Healthcare Provider Details

I. General information

NPI: 1003306812
Provider Name (Legal Business Name): TABITHA THREATT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 INDIANA AVE
LUBBOCK TX
79415-3364
US

IV. Provider business mailing address

7703 FLOYD CURL DRIVE MAIL CODE 7742
SAN ANTONIO TX
78229-5544
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2373
  • Fax: 806-743-4354
Mailing address:
  • Phone: 210-567-5711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberU9095
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: