Provider Demographics
NPI:1043215536
Name:CLIBURN, GRETCHEN B (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:B
Last Name:CLIBURN
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 1:4071 TATES CREEK CENTRE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-3094
Mailing Address - Country:US
Mailing Address - Phone:859-226-0206
Mailing Address - Fax:859-226-0207
Practice Address - Street 1:4071 TATES CREEK CENTRE DR STE 202
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-3094
Practice Address - Country:US
Practice Address - Phone:859-226-0206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S52793Medicare UPIN
KYS52793Medicare UPIN
KY9500383600Medicare ID - Type Unspecified
KY1369309Medicare ID - Type Unspecified