Provider Demographics
NPI:1497971865
Name:TIBOR, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:TIBOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4265
Mailing Address - Country:US
Mailing Address - Phone:760-924-4084
Mailing Address - Fax:
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:760-924-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60721917207X00000X
CAA106811207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine