Provider Demographics
NPI:1497785778
Name:GRIBBIN, DELYS V (PA)
Entity Type:Individual
Prefix:MRS
First Name:DELYS
Middle Name:V
Last Name:GRIBBIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DELYS
Other - Middle Name:V
Other - Last Name:RAYSIDE-GRIBBIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:3022 WILLIAMS DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4600
Mailing Address - Country:US
Mailing Address - Phone:703-738-5737
Mailing Address - Fax:703-573-2959
Practice Address - Street 1:111 E MILLER ST
Practice Address - Street 2:
Practice Address - City:DILLEY
Practice Address - State:TX
Practice Address - Zip Code:78017-3912
Practice Address - Country:US
Practice Address - Phone:830-965-1684
Practice Address - Fax:830-965-1278
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03945363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N7150OtherBCBS
Q10627Medicare UPIN