Basic Information
| Provider Information | |||||||||
| NPI: | 1104072388 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIBERT | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 COMMERCE LANE | ||||||||
| Address2: | P.O. BOX 407 | ||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136173739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868191 | ||||||||
| FaxNumber: | 3153861410 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 COMMERCE LANE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136173739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868191 | ||||||||
| FaxNumber: | 3153861410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2008 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 014002 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 110809 | 01 | KS | BLUE CROSS/BLUE SHIELD GROUP | OTHER | 100427890B | 05 | KS | MEDICAID | 01995615 | 05 | NY | MEDICAID |