Provider Demographics
NPI:1073657789
Name:RIEBE, SANDRA J (PA-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:RIEBE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 S PIETY ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:54011-9133
Mailing Address - Country:US
Mailing Address - Phone:715-273-4585
Mailing Address - Fax:
Practice Address - Street 1:927 CHURCHILL ST W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6605
Practice Address - Country:US
Practice Address - Phone:651-439-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO555207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
005972OtherKAISER-COMMERCIAL NUMBER