Provider Demographics
NPI:1497787584
Name:MCKIBBIN-VAUGHAN, TOM (PA)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:MCKIBBIN-VAUGHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WESTAGE BUSINESS CTR DR
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-2281
Mailing Address - Country:US
Mailing Address - Phone:845-231-5600
Mailing Address - Fax:845-231-5489
Practice Address - Street 1:2400 US ROUTE 9
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-4725
Practice Address - Country:US
Practice Address - Phone:518-537-4900
Practice Address - Fax:518-537-5977
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009679363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400024258Medicare PIN
NYQ21054Medicare UPIN