Provider Demographics
NPI:1679805105
Name:MCLISTER, JARED MATTHEW (PAC)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MATTHEW
Last Name:MCLISTER
Suffix:
Gender:M
Credentials:PAC
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE
Mailing Address - Street 2:STE 112
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-731-3111
Mailing Address - Fax:920-731-7133
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:STE 101
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3734
Practice Address - Country:US
Practice Address - Phone:320-762-1144
Practice Address - Fax:320-762-1935
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
WI4316-23363A00000X
MN10698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM2139118OtherDEA
MN970005489Medicare UPIN