Provider Demographics
NPI:1225031776
Name:HADENFELDT, JASON R (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:HADENFELDT
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 1:620 N DIERS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4985
Mailing Address - Country:US
Mailing Address - Phone:308-384-5400
Mailing Address - Fax:308-384-5201
Practice Address - Street 1:620 N DIERS AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4985
Practice Address - Country:US
Practice Address - Phone:308-384-5400
Practice Address - Fax:308-384-5201
Is Sole Proprietor?:No
Enumeration Date:2005-05-28
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE986363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1225031776OtherNPI
NE47063010113Medicaid
NE47063010113Medicaid
NEP42244Medicare UPIN
NE10025800600Medicaid