Basic Information
| Provider Information | |||||||||
| NPI: | 1235240771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKIBBIN-VAUGHAN | ||||||||
| FirstName: | DEIRDRE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 COLUMBIA ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454731188 | ||||||||
| FaxNumber: | 8454730896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 COLUMBIA ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454731188 | ||||||||
| FaxNumber: | 8454730896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 004393 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MV0351279 | 01 | NY | DEA | OTHER |