Provider Demographics
NPI:1174631485
Name:NIEBOER, ALAN L (GNP)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:L
Last Name:NIEBOER
Suffix:
Gender:M
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:212 S SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1548
Mailing Address - Country:US
Mailing Address - Phone:231-924-3300
Mailing Address - Fax:231-924-1320
Practice Address - Street 1:204 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1181
Practice Address - Country:US
Practice Address - Phone:231-924-1800
Practice Address - Fax:231-924-1810
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120574363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4383367Medicaid