Provider Demographics
NPI:1639781230
Name:TIBERT, AMANDA MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAE
Last Name:TIBERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MAE
Other - Last Name:SAXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:83 HERRICK ST STE 2004
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2757
Mailing Address - Country:US
Mailing Address - Phone:978-927-4800
Mailing Address - Fax:
Practice Address - Street 1:83 HERRICK ST STE 2004
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2757
Practice Address - Country:US
Practice Address - Phone:978-927-4800
Practice Address - Fax:978-777-4792
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1173579OtherNCCPA CERTIFICATION
MAPA7714OtherPHYSICIAN ASSISTANT PRACTICING LICENSE