Basic Information
Provider Information | |||||||||
NPI: | 1962482042 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIBAL | ||||||||
FirstName: | JACK | ||||||||
MiddleName: | GUILLERMO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3617 S PACIFIC HWY | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975018957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5415356239 | ||||||||
FaxNumber: | 5415121026 | ||||||||
Practice Location | |||||||||
Address1: | 4940 HAMRICK RD | ||||||||
Address2: |   | ||||||||
City: | CENTRAL POINT | ||||||||
State: | OR | ||||||||
PostalCode: | 975023072 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416903600 | ||||||||
FaxNumber: | 5416643735 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 14456 | CA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA184052 | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.