Basic Information
| Provider Information | |||||||||
| NPI: | 1487783270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOBCZYK | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 RIDGE ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123225899 | ||||||||
| FaxNumber: | 7123225730 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 RIDGE ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123225899 | ||||||||
| FaxNumber: | 7123225730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001791 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1053300020 | 01 | IA | GROUP NPI NUMBER | OTHER | 001791 | 01 | IA | LICENSE NUMBER | OTHER | 51011042 | 01 | IA | STATE CONTROLLED SUBSTANC | OTHER |