Provider Demographics
NPI:1902205230
Name:LOBAN, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LOBAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5049 FOX CREEK HOLLOW
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-0000
Mailing Address - Country:US
Mailing Address - Phone:208-201-3467
Mailing Address - Fax:
Practice Address - Street 1:5049 FOX CREEK HOLLOW
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-0000
Practice Address - Country:US
Practice Address - Phone:208-201-3467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY127612300OtherMEDICAID PROVIDER NUMBER