Provider Demographics
NPI:1457718843
Name:LIBBOS, THEA M (PA-C)
Entity Type:Individual
Prefix:
First Name:THEA
Middle Name:M
Last Name:LIBBOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THEA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:FILE 57326
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7326
Mailing Address - Country:US
Mailing Address - Phone:800-926-8273
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63893363A00000X
TXPA13908363A00000X
NY019399363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical