Healthcare Provider Details

I. General information

NPI: 1033601125
Provider Name (Legal Business Name): MARISSA CLAIRE SJOBERG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISSA CLAIRE KOCH PA-C

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 R ST STE 100
LINCOLN NE
68503-3799
US

IV. Provider business mailing address

4545 R ST STE 100
LINCOLN NE
68503-3799
US

V. Phone/Fax

Practice location:
  • Phone: 402-465-4545
  • Fax: 402-465-9011
Mailing address:
  • Phone: 402-465-4545
  • Fax: 402-465-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2258
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: