Provider Demographics
NPI:1174094130
Name:RIBECKY, JACOB (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:RIBECKY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5622
Mailing Address - Country:US
Mailing Address - Phone:610-628-8372
Mailing Address - Fax:610-628-8648
Practice Address - Street 1:1736 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-5656
Practice Address - Country:US
Practice Address - Phone:610-628-8372
Practice Address - Fax:610-628-8648
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN660613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered