Provider Demographics
NPI:1619386570
Name:TIBETT, MAGDALENA
Entity type:Individual
Prefix:
First Name:MAGDALENA
Middle Name:
Last Name:TIBETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MONTAUK HIGHWAY
Mailing Address - Street 2:SUITE 3-1
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4910
Mailing Address - Country:US
Mailing Address - Phone:631-669-1171
Mailing Address - Fax:
Practice Address - Street 1:1111 MONTAUK HWY
Practice Address - Street 2:SUITE 3-1
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4910
Practice Address - Country:US
Practice Address - Phone:631-669-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant