Provider Demographics
NPI:1326040973
Name:HEAD, ANDRIA JEAN (PAC)
Entity Type:Individual
Prefix:
First Name:ANDRIA
Middle Name:JEAN
Last Name:HEAD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2115 N KANSAS AVE
Mailing Address - Street 2:CHILDREN & ADOLESCENT CLINIC PC
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901
Mailing Address - Country:US
Mailing Address - Phone:402-463-6828
Mailing Address - Fax:402-463-4767
Practice Address - Street 1:2115 N KANSAS AVE
Practice Address - Street 2:CHILDREN & ADOLESCENT CLINIC PC
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901
Practice Address - Country:US
Practice Address - Phone:402-463-6828
Practice Address - Fax:402-463-4767
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE1317208000000X
IA01493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47063717813Medicaid
P96346Medicare UPIN