Provider Demographics
NPI:1114584018
Name:MATIBIRI, PAIDAMOYO R (APRN)
Entity Type:Individual
Prefix:
First Name:PAIDAMOYO
Middle Name:R
Last Name:MATIBIRI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3403
Mailing Address - Country:US
Mailing Address - Phone:858-301-2999
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL VILLAGE DR # 1
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-26
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014714363L00000X, 363LF0000X
OH0031276363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner