Provider Demographics
NPI:1316252356
Name:LOBODA, NIKOLAY NIKOLAYEVICH (PA)
Entity type:Individual
Prefix:
First Name:NIKOLAY
Middle Name:NIKOLAYEVICH
Last Name:LOBODA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 S SANTA FE AVE
Mailing Address - Street 2:#F-52
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5067
Mailing Address - Country:US
Mailing Address - Phone:951-654-6596
Mailing Address - Fax:
Practice Address - Street 1:1692 S SANTA FE AVE
Practice Address - Street 2:#F-52
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5067
Practice Address - Country:US
Practice Address - Phone:951-654-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-14
Last Update Date:2010-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant