Provider Demographics
NPI:1053985929
Name:SOEBOER, ANNISA NABILA (PA-C)
Entity type:Individual
Prefix:
First Name:ANNISA
Middle Name:NABILA
Last Name:SOEBOER
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 1:2000 MOWRY AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 MOWRY AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1716
Practice Address - Country:US
Practice Address - Phone:707-771-5687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA61379OtherPHYSICIAN ASSISTANT BOARD
CAPA61379OtherPHYSICIAN ASSISTANT BOARD