Provider Demographics
NPI:1649481409
Name:KIBBY, DAVID A (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:KIBBY
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 1:5719 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1985
Mailing Address - Country:US
Mailing Address - Phone:315-251-3100
Mailing Address - Fax:315-449-9923
Practice Address - Street 1:5719 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1985
Practice Address - Country:US
Practice Address - Phone:315-251-3100
Practice Address - Fax:315-449-9923
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02925964Medicaid
NYJ400002999OtherMEDICARE PTAN#
NY02925964Medicaid
NYPA2002Medicare PIN
NYJ400038351Medicare PIN