Provider Demographics
NPI:1922356658
Name:TIBBITS, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:TIBBITS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5701
Mailing Address - Country:US
Mailing Address - Phone:541-237-5040
Mailing Address - Fax:
Practice Address - Street 1:1833 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5701
Practice Address - Country:US
Practice Address - Phone:541-237-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201707245NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner