Provider Demographics
NPI:1245403377
Name:JAN H NYBOER MD
Entity Type:Organization
Organization Name:JAN H NYBOER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERNADINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NYBOER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-561-1167
Mailing Address - Street 1:9350 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-4613
Mailing Address - Country:US
Mailing Address - Phone:907-561-1167
Mailing Address - Fax:907-561-7051
Practice Address - Street 1:9350 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-4613
Practice Address - Country:US
Practice Address - Phone:907-561-1167
Practice Address - Fax:907-561-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD1135332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG486Medicaid
AKK0000WFBTQMedicare PIN
AK4861190001Medicare NSC