MEDICARE: COLLIN SCOTT TIBBITTS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	249773	AZ
2	367500000X	Certified Registered Nurse Anesthetist	249773	AZ

General Provider Information

NPI Number	:	1720862634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN SCOTT TIBBITTS RN

Provider Business Mailing Address
First Line	:	41274 N CAMBRIA DR
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85140-3173
Country	:	US
Telephone Number	:	480-202-2232
Fax Number	:

Provider Business Practice Location Address
First Line	:	41274 N CAMBRIA DR
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85140-3173
Country	:	US
Telephone Number	:	801-436-4517
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2023
Last Update Date	:	05/26/2026

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