Basic Information
| Provider Information | |||||||||
| NPI: | 1245632462 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEIBELSPERGER | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | THERESA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PALMOWSKI | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | THERESA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2337 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132202337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157015610 | ||||||||
| FaxNumber: | 3154223909 | ||||||||
| Practice Location | |||||||||
| Address1: | 7785 N STATE ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | LOWVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133671229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153765488 | ||||||||
| FaxNumber: | 3153765442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2014 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 018049 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 04013778 | 05 | NY | MEDICAID |