Provider Demographics
NPI:1669013785
Name:SIEBER, ANDREW (SOIDC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SIEBER
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SEA HUNTER WAY
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-6012
Mailing Address - Country:US
Mailing Address - Phone:860-462-2636
Mailing Address - Fax:
Practice Address - Street 1:304 SEA HUNTER WAY
Practice Address - Street 2:
Practice Address - City:SNEADS FERRY
Practice Address - State:NC
Practice Address - Zip Code:28460-6012
Practice Address - Country:US
Practice Address - Phone:860-462-2636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCL02AOtherSOIDC