Provider Demographics
NPI:1932125309
Name:MAYBERRY, TAMILA GALE (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMILA
Middle Name:GALE
Last Name:MAYBERRY
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 1:5400 FRANTZ RD STE 250
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-6102
Mailing Address - Country:US
Mailing Address - Phone:614-533-6497
Mailing Address - Fax:
Practice Address - Street 1:915 PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-5547
Practice Address - Country:US
Practice Address - Phone:407-891-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001988RX363A00000X
TN1067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0343562Medicaid
TNP00173383OtherRAILROAD MEDICARE
TNP00173383OtherRAILROAD MEDICARE