Provider Demographics
NPI:1265524508
Name:JAN K. SIEBERSMA, PC
Entity type:Organization
Organization Name:JAN K. SIEBERSMA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIEBERSMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-522-9793
Mailing Address - Street 1:2100 S TRIVIZ DR STE H
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-0601
Mailing Address - Country:US
Mailing Address - Phone:505-522-9793
Mailing Address - Fax:505-532-9019
Practice Address - Street 1:2100 S TRIVIZ DR STE H
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-0601
Practice Address - Country:US
Practice Address - Phone:505-522-9793
Practice Address - Fax:505-532-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM92-345207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F42876Medicare UPIN
585889136RMedicare ID - Type Unspecified