Provider Demographics
NPI:1629084900
Name:TIEDE, JASON ALAN (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALAN
Last Name:TIEDE
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 1:1800 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1520
Mailing Address - Country:US
Mailing Address - Phone:417-782-5000
Mailing Address - Fax:417-782-2945
Practice Address - Street 1:1800 W 30TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1520
Practice Address - Country:US
Practice Address - Phone:417-782-5000
Practice Address - Fax:417-782-2945
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117822363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000426956OtherBLUE CROSS BLUE SHIELD
Q61080Medicare UPIN
KS426956Medicare ID - Type Unspecified