Provider Demographics
NPI:1669858841
Name:TIBBETTS, DONALD JASON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:JASON
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HITCHCOCK WAY
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-4125
Mailing Address - Country:US
Mailing Address - Phone:603-695-2830
Mailing Address - Fax:
Practice Address - Street 1:100 HITCHCOCK WAY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-4125
Practice Address - Country:US
Practice Address - Phone:603-695-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant