Provider Demographics
NPI:1235199571
Name:GANDY, JANE M (PAC)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:M
Last Name:GANDY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 N LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50138
Mailing Address - Country:US
Mailing Address - Phone:515-718-5389
Mailing Address - Fax:641-828-5312
Practice Address - Street 1:1607 N LINCOLN ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IA
Practice Address - Zip Code:50138
Practice Address - Country:US
Practice Address - Phone:515-718-5389
Practice Address - Fax:641-828-5312
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1076363A00000X
IA001076363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42968100Medicaid
WI42968100Medicaid
IAS40146Medicare UPIN