Provider Demographics
NPI:1265452007
Name:TIBBS, DARYL E (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:E
Last Name:TIBBS
Suffix:
Gender:M
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 1:360 SAN MIGUEL DR STE 501
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7831
Mailing Address - Country:US
Mailing Address - Phone:949-720-1170
Mailing Address - Fax:916-773-3353
Practice Address - Street 1:360 SAN MIGUEL DR STE 501
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-720-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18738207N00000X
NC001000261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty