Provider Demographics
NPI:1972030922
Name:ASSOBMO, LOIC RICKEL (CNP)
Entity Type:Individual
Prefix:
First Name:LOIC
Middle Name:RICKEL
Last Name:ASSOBMO
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:2150 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-739-5676
Practice Address - Fax:413-733-5860
Is Sole Proprietor?:No
Enumeration Date:2017-05-20
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2310024363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110126197AMedicaid