Provider Demographics
NPI:1356326656
Name:TIBBETTS, GRANT PARKER (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:PARKER
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:MD
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 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1900
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-761-4201
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1751662085R0202X
WAMD604567982085R0202X
AK4693171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0335106OtherL&I-TRA PIERCE COUNTY
WA0335194OtherL&I- TRA KING COUNTY
WA0394949OtherL&I-DIAGNOSTIC IMAGING NW
OR500698491Medicaid
WA0335196OtherL&I-UNION AVE OPEN MRI
WA2036409Medicaid