Provider Demographics
NPI:1114574696
Name:BAJO, JOSE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:BAJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 BOYCE ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-4348
Mailing Address - Country:US
Mailing Address - Phone:305-903-4145
Mailing Address - Fax:
Practice Address - Street 1:800 N ALPHA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4320
Practice Address - Country:US
Practice Address - Phone:308-382-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE000-00-00363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner