Provider Demographics
NPI:1205276474
Name:TIBBITTS, BRANDON (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:TIBBITTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:113 ELM ST STE 304
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3739
Mailing Address - Country:US
Mailing Address - Phone:860-741-2225
Mailing Address - Fax:860-741-2229
Practice Address - Street 1:1290 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-4337
Practice Address - Country:US
Practice Address - Phone:860-777-1280
Practice Address - Fax:860-777-1276
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003752207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology