Provider Demographics
NPI:1659301208
Name:THIBERT, MICHAEL D (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:THIBERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3474
Mailing Address - Country:US
Mailing Address - Phone:530-842-1267
Mailing Address - Fax:530-842-9121
Practice Address - Street 1:475 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3474
Practice Address - Country:US
Practice Address - Phone:530-842-1267
Practice Address - Fax:530-842-9121
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00165970OtherRAILROAD MEDICARE
CAPA12103Medicaid
CAPA12103Medicaid
CAP00165970OtherRAILROAD MEDICARE
CA0PA121031Medicare ID - Type Unspecified
CA0PA121032Medicare PIN