Basic Information
Provider Information | |||||||||
NPI: | 1366607301 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IPE | ||||||||
FirstName: | SIBI | ||||||||
MiddleName: | VARGHESE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VARGHESE | ||||||||
OtherFirstName: | SIBI | ||||||||
OtherMiddleName: | VARGHESE | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1105 CENTRAL EXPY N STE 235 | ||||||||
Address2: |   | ||||||||
City: | ALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 750136135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727476042 | ||||||||
FaxNumber: | 9727476043 | ||||||||
Practice Location | |||||||||
Address1: | 1105 CENTRAL EXPY N STE 235 | ||||||||
Address2: |   | ||||||||
City: | ALLEN | ||||||||
State: | TX | ||||||||
PostalCode: | 750136135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9727476042 | ||||||||
FaxNumber: | 9727476043 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2008 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05723 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | P05723 | 01 | TX | MEDICAL LICENSE | OTHER |