Provider Demographics
NPI:1154939064
Name:LIEBMANN, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LIEBMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BUNN DRIVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-6493
Mailing Address - Country:US
Mailing Address - Phone:609-683-4999
Mailing Address - Fax:
Practice Address - Street 1:208 BUNN DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-2851
Practice Address - Country:US
Practice Address - Phone:609-683-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346148363L00000X
NJ26NJ01046900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner