Provider Demographics
NPI:1588091565
Name:DIBERT, KEVIN LEE
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:DIBERT
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 1:259 ROSE CT N
Mailing Address - Street 2:
Mailing Address - City:DELMONT
Mailing Address - State:PA
Mailing Address - Zip Code:15626-1555
Mailing Address - Country:US
Mailing Address - Phone:724-787-5708
Mailing Address - Fax:
Practice Address - Street 1:259 ROSE CT N
Practice Address - Street 2:
Practice Address - City:DELMONT
Practice Address - State:PA
Practice Address - Zip Code:15626-1555
Practice Address - Country:US
Practice Address - Phone:724-787-5708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN529489L390200000X
PA101293367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program