Provider Demographics
NPI:1316548142
Name:ENEBOE, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:ENEBOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3948 BEN WALTERS LN
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7708
Mailing Address - Country:US
Mailing Address - Phone:907-235-7701
Mailing Address - Fax:
Practice Address - Street 1:3948 BEN WALTERS LN
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7708
Practice Address - Country:US
Practice Address - Phone:907-235-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020987Medicaid