Provider Demographics
NPI:1033855796
Name:TRIBBLE, MARY BAILEY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BAILEY
Last Name:TRIBBLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:ROUND TOP
Mailing Address - State:TX
Mailing Address - Zip Code:78954-0183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1260 E 1ST AVE UNIT A
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-3792
Practice Address - Country:US
Practice Address - Phone:720-716-4518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007327363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant