Provider Demographics
NPI:1720066996
Name:NEBERGALL, ROBYN L (PAC)
Entity Type:Individual
Prefix:
First Name:ROBYN
Middle Name:L
Last Name:NEBERGALL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772-1100
Mailing Address - Country:US
Mailing Address - Phone:563-886-2182
Mailing Address - Fax:563-886-2732
Practice Address - Street 1:1412 CEDAR ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IA
Practice Address - Zip Code:52772-1100
Practice Address - Country:US
Practice Address - Phone:563-886-2182
Practice Address - Fax:563-886-2732
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000957363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS57539Medicare UPIN
IA56618Medicare ID - Type Unspecified