Provider Demographics
NPI:1235122284
Name:SJOBERG, CHRISTOPHER JAY (NP)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JAY
Last Name:SJOBERG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18001 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3803
Mailing Address - Country:US
Mailing Address - Phone:208-367-3069
Mailing Address - Fax:208-367-3002
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-3069
Practice Address - Fax:208-367-3002
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP903A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1250802Medicare Oscar/Certification