Provider Demographics
NPI:1770851602
Name:NEIBAUR, JACOB C (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:C
Last Name:NEIBAUR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6276 S RAINBOW BLVD
Mailing Address - Street 2:#100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-3242
Mailing Address - Country:US
Mailing Address - Phone:702-396-4165
Mailing Address - Fax:
Practice Address - Street 1:6276 S RAINBOW BLVD
Practice Address - Street 2:#100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3242
Practice Address - Country:US
Practice Address - Phone:702-396-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2013-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1313363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical