Provider Demographics
NPI:1174810667
Name:NIEBOER, LORI SUE (PA-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:SUE
Last Name:NIEBOER
Suffix:
Gender:F
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 1:4685 BELDING RD NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9605
Mailing Address - Country:US
Mailing Address - Phone:616-252-3100
Mailing Address - Fax:
Practice Address - Street 1:4685 BELDING RD NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9605
Practice Address - Country:US
Practice Address - Phone:616-252-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006100363AM0700X
MI5601006254363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical