Provider Demographics
NPI:1306084348
Name:KIBBY, DOREEN JOY (PA-C)
Entity type:Individual
Prefix:MS
First Name:DOREEN
Middle Name:JOY
Last Name:KIBBY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DOREEN
Other - Middle Name:JOY
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:2865 SIENA HEIGHTS DR
Practice Address - Street 2:SUITE 331-A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4167
Practice Address - Country:US
Practice Address - Phone:702-407-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1156363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1750383360Medicaid
NVGE651Z (CQ328A)Medicare PIN
NVGE651Y (CQ328B)Medicare PIN