Provider Demographics
NPI:1811005606
Name:NYBOER, JAN H (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:H
Last Name:NYBOER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9350 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507
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
Practice Address - Country:US
Practice Address - Phone:907-561-1167
Practice Address - Fax:907-561-7051
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD1135207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1811005606OtherNPI
AKMD1135Medicaid
AK1811005606OtherNPI
AKMD1135Medicaid
AK00WFBTQAMedicare ID - Type Unspecified