Basic Information
| Provider Information | |||||||||
| NPI: | 1679512396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIBERIA | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | MARY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARMODY | ||||||||
| OtherFirstName: | JANET | ||||||||
| OtherMiddleName: | MARY | ||||||||
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| OtherCredential: | PNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 BAYBERRY CIR | ||||||||
| Address2: | |||||||||
| City: | POESTENKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121402309 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1092 MADISON AVE | ||||||||
| Address2: | PEDIATRICS | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122082248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185252445 | ||||||||
| FaxNumber: | 5184757069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 06/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | F380750 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01878459 | 05 | NY | MEDICAID |