Provider Demographics
NPI:1578534921
Name:HIBMA, ANDREA (PA)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:
Last Name:HIBMA
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 1:151 W LAKE ST STE 1500
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4124
Mailing Address - Country:US
Mailing Address - Phone:970-495-8450
Mailing Address - Fax:
Practice Address - Street 1:151 W LAKE ST STE 1500
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4124
Practice Address - Country:US
Practice Address - Phone:970-495-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1322363A00000X
IA001810363A00000X
CO2087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO57139024Medicaid
CO57139024Medicaid
COQ47124Medicare UPIN