Provider Demographics
NPI:1851536718
Name:TYBURSKI, IRENE VAN GAALEN (PA-C)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:VAN GAALEN
Last Name:TYBURSKI
Suffix:
Gender:F
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 1:227 ST. PAUL PLACE
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202
Mailing Address - Country:US
Mailing Address - Phone:410-332-9700
Mailing Address - Fax:410-545-4330
Practice Address - Street 1:227 ST. PAUL PLACE
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:410-332-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant