MEDICARE: LUCY WACHERA KIBE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MA056071	PA

General Provider Information

NPI Number	:	1558707810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCY WACHERA KIBE PA-C

Provider Business Mailing Address
First Line	:	1845 N 23RD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19121-2055
Country	:	US
Telephone Number	:	215-235-3110
Fax Number	:	215-235-4441

Provider Business Practice Location Address
First Line	:	1845 N 23RD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19121-2055
Country	:	US
Telephone Number	:	215-235-3110
Fax Number	:	215-235-4441

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2013
Last Update Date	:	05/14/2013

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