Provider Demographics
NPI:1396267175
Name:KOEBERT, JULIA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:ROSE
Last Name:KOEBERT
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 1:67 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3717
Mailing Address - Country:US
Mailing Address - Phone:516-592-9017
Mailing Address - Fax:
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:516-592-9017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000000000207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine