Provider Demographics
NPI:1316466998
Name:LOCKHART, TABITHA JOY (PA-C)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:JOY
Last Name:LOCKHART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 GEORGE ST APT 4E
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6682
Mailing Address - Country:US
Mailing Address - Phone:330-316-5627
Mailing Address - Fax:203-737-1077
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-645-2049
Practice Address - Fax:203-737-1077
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005231RX363A00000X
CT4777363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant