Provider Demographics
NPI:1245632462
Name:LEIBELSPERGER, KIMBERLY THERESA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:THERESA
Last Name:LEIBELSPERGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:THERESA
Other - Last Name:PALMOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 2337
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-2337
Mailing Address - Country:US
Mailing Address - Phone:315-701-5610
Mailing Address - Fax:315-422-3909
Practice Address - Street 1:7785 N STATE ST
Practice Address - Street 2:SUITE 250
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1229
Practice Address - Country:US
Practice Address - Phone:315-376-5488
Practice Address - Fax:315-376-5442
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04013778Medicaid
NYJ400215878Medicare PIN
NYJ400183047Medicare PIN