Provider Demographics
NPI:1891972261
Name:TIBERY, CECILIA MAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:MAURA
Last Name:TIBERY
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 1:5601 LOCH RAVEN BLVD
Mailing Address - Street 2:GOOD SAMARITAN HOSPITAL, POB 406
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2905
Mailing Address - Country:US
Mailing Address - Phone:443-444-4700
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL, POB 406
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2905
Practice Address - Country:US
Practice Address - Phone:443-444-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant