Provider Demographics
NPI:1487735569
Name:HIBBS, JONATHAN R (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:HIBBS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E MANITOBA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 E MANITOBA AVE STE 101
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3885
Practice Address - Country:US
Practice Address - Phone:509-925-6100
Practice Address - Fax:509-925-7604
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5225486207R00000X, 207RI0200X
WAMD60223697207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038578Medicaid