Healthcare Provider Details

I. General information

NPI: 1295809564
Provider Name (Legal Business Name): AMY L. TIBBITS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY L LUTHER

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 CLAY ST
DARLINGTON WI
53530-1225
US

IV. Provider business mailing address

800 CLAY ST
DARLINGTON WI
53530-1228
US

V. Phone/Fax

Practice location:
  • Phone: 608-776-4497
  • Fax: 608-776-2317
Mailing address:
  • Phone: 608-776-4497
  • Fax: 608-776-2837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2064-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: