Provider Demographics
NPI:1417915588
Name:IBE, CHIGOZIE L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHIGOZIE
Middle Name:L
Last Name:IBE
Suffix:
Gender:M
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 1:995 BUCK DR
Mailing Address - Street 2:
Mailing Address - City:NAZARETH
Mailing Address - State:PA
Mailing Address - Zip Code:18064-8668
Mailing Address - Country:US
Mailing Address - Phone:610-588-7155
Mailing Address - Fax:
Practice Address - Street 1:382 EPPS ST
Practice Address - Street 2:
Practice Address - City:WIND GAP
Practice Address - State:PA
Practice Address - Zip Code:18091-9717
Practice Address - Country:US
Practice Address - Phone:610-863-8598
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051543363A00000X
NJ25MP00120400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5005698OtherKEYSTONE HEALTHPLAN CENTR
PA5005698OtherKEYSTONE HEALTHPLAN CENTR
PAQ59428Medicare UPIN
PA097135QG8Medicare ID - Type Unspecified