Basic Information
| Provider Information | |||||||||
| NPI: | 1174631485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEBOER | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | GNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 S SULLIVAN AVE | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494121548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319243300 | ||||||||
| FaxNumber: | 2319241320 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494121181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319241800 | ||||||||
| FaxNumber: | 2319241810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2006 | ||||||||
| LastUpdateDate: | 12/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 4704120574 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 4383367 | 05 | MI | MEDICAID |