Provider Demographics
NPI:1225420128
Name:KOEBERLE, BRIAN (RN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KOEBERLE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BROADWAY
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-1527
Mailing Address - Country:US
Mailing Address - Phone:916-874-9227
Mailing Address - Fax:
Practice Address - Street 1:4600 BROADWAY
Practice Address - Street 2:SUITE 2200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1527
Practice Address - Country:US
Practice Address - Phone:916-874-9227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95039802163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse