Provider Demographics
NPI:1861498610
Name:TIBBS, PATRICIA A (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:A
Last Name:TIBBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6525
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-6525
Mailing Address - Country:US
Mailing Address - Phone:601-477-3550
Mailing Address - Fax:601-477-9158
Practice Address - Street 1:1203 AVENUE B
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39437
Practice Address - Country:US
Practice Address - Phone:601-477-3550
Practice Address - Fax:601-477-9158
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS15492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118835Medicaid
MS00118835Medicaid