Provider Demographics
NPI:1053396457
Name:KOEBERNICK, MICHAEL L (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KOEBERNICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2222 S 16TH STREET
Mailing Address - Street 2:MEDICAL TOWER B, #305
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502
Mailing Address - Country:US
Mailing Address - Phone:402-488-3002
Mailing Address - Fax:402-483-8787
Practice Address - Street 1:575 S 70TH ST
Practice Address - Street 2:#400
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2471
Practice Address - Country:US
Practice Address - Phone:402-488-3002
Practice Address - Fax:402-483-8787
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2009-12-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE937363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47061995513Medicaid
NE47061995513Medicaid