Basic Information
| Provider Information | |||||||||
| NPI: | 1457718843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIBBOS | ||||||||
| FirstName: | THEA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16020 PARK VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786813573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122464488 | ||||||||
| FaxNumber: | 5122441013 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 W 38TH ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124544561 | ||||||||
| FaxNumber: | 5124067330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2016 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 019399 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 019399 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 019399 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA13908 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.