Provider Demographics
NPI:1194184077
Name:DIBBLE, QURRATUL-AYN (PA)
Entity Type:Individual
Prefix:
First Name:QURRATUL-AYN
Middle Name:
Last Name:DIBBLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E 16TH ST
Mailing Address - Street 2:APT # 3K
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-4351
Mailing Address - Country:US
Mailing Address - Phone:585-410-2958
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-5454
Practice Address - Fax:212-746-8861
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant