Provider Demographics
NPI:1083425243
Name:MCKIBBEN, TYLER PATRICK (AP)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:PATRICK
Last Name:MCKIBBEN
Suffix:
Gender:
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1146
Mailing Address - Country:US
Mailing Address - Phone:573-783-3341
Mailing Address - Fax:
Practice Address - Street 1:611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1146
Practice Address - Country:US
Practice Address - Phone:573-783-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO363A00000X
MO2025005124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2025005124OtherASSISTANT PHYSICIAN MO LICENSE