Provider Demographics
NPI:1558765040
Name:TRIBOLET, TAMARYN PARKS (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMARYN
Middle Name:PARKS
Last Name:TRIBOLET
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAMARYN
Other - Middle Name:
Other - Last Name:PARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5716 CLEVELAND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1784
Mailing Address - Country:US
Mailing Address - Phone:757-490-4802
Mailing Address - Fax:757-226-9044
Practice Address - Street 1:5716 CLEVELAND ST STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1784
Practice Address - Country:US
Practice Address - Phone:757-502-8583
Practice Address - Fax:757-226-9044
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09469363A00000X
VA0110006015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVR782AOtherMEDICARE PIN
TX342064801Medicaid