Healthcare Provider Details

I. General information

NPI: 1174094130
Provider Name (Legal Business Name): JACOB RIBECKY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1736 HAMILTON ST
ALLENTOWN PA
18104-5656
US

IV. Provider business mailing address

24 S 18TH ST
ALLENTOWN PA
18104-5622
US

V. Phone/Fax

Practice location:
  • Phone: 610-628-8372
  • Fax: 610-628-8648
Mailing address:
  • Phone: 610-628-8372
  • Fax: 610-628-8648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN660613
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: