Provider Demographics
NPI:1346218773
Name:HILBORNE, KENNETH HENRY JR (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:HENRY
Last Name:HILBORNE
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669
Mailing Address - Country:US
Mailing Address - Phone:315-393-4728
Mailing Address - Fax:
Practice Address - Street 1:4 COMMERCE LANE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-386-8191
Practice Address - Fax:315-386-1410
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330919363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid
161568985LAIOtherBCBS
54528LMedicare ID - Type Unspecified
R94375Medicare UPIN