Provider Demographics
NPI:1275257776
Name:TIBBS, CONOR WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:CONOR
Middle Name:WILLIAM
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 1:6221 METROPOLITAN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-3096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6221 METROPOLITAN ST STE 201
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-3096
Practice Address - Country:US
Practice Address - Phone:760-753-7127
Practice Address - Fax:760-334-0399
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
63761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty