Provider Demographics
NPI:1104072388
Name:KIBERT, JESSE J (PA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:J
Last Name:KIBERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 COMMERCE LANE
Mailing Address - Street 2:P.O. BOX 407
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-3739
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-386-1410
Practice Address - Street 1:4 COMMERCE LANE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-3739
Practice Address - Country:US
Practice Address - Phone:315-386-8191
Practice Address - Fax:315-386-1410
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS363AM0700X
NY014002363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110809OtherBLUE CROSS/BLUE SHIELD GROUP
KS100427890BMedicaid
NY01995615Medicaid
NY01995615Medicaid
KS110809Medicare PIN
KS178968Medicare Oscar/Certification