Basic Information
| Provider Information | |||||||||
| NPI: | 1346218773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HILBORNE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | HENRY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 ELIZABETH ST | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153934728 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4 COMMERCE LANE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153868191 | ||||||||
| FaxNumber: | 3153861410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 12/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F330919 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 01995615 | 05 | NY | MEDICAID | 161568985LAI | 01 | BCBS | OTHER |