Provider Demographics
NPI:1356867733
Name:KIBILOSKI, DIANE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:KIBILOSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1400 MERCY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1836
Mailing Address - Country:US
Mailing Address - Phone:231-733-1326
Mailing Address - Fax:231-733-0449
Practice Address - Street 1:1400 MERCY DR STE 100
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1836
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-733-0449
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601008307363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical