Provider Demographics
NPI:1891469615
Name:GARIBAY, MAYRA (PA)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:GARIBAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10755 163RD PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8861
Mailing Address - Country:US
Mailing Address - Phone:708-873-1187
Mailing Address - Fax:
Practice Address - Street 1:10755 163RD PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-8861
Practice Address - Country:US
Practice Address - Phone:708-873-1187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085008881363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program