Basic Information
| Provider Information | |||||||||
| NPI: | 1518389238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIBBEN | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 LEROY ST | ||||||||
| Address2: | |||||||||
| City: | POTSDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136761786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152653300 | ||||||||
| FaxNumber: | 3152616025 | ||||||||
| Practice Location | |||||||||
| Address1: | 7060 ERIE RD | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140479430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169470408 | ||||||||
| FaxNumber: | 7169470413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2014 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 017286 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.