Provider Demographics
NPI:1710125919
Name:LOONTJER, KEVIN GARY (MPAS PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:GARY
Last Name:LOONTJER
Suffix:
Gender:M
Credentials:MPAS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 N CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-7716
Mailing Address - Country:US
Mailing Address - Phone:402-721-0090
Mailing Address - Fax:402-721-9661
Practice Address - Street 1:2740 N CLARKSON ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-7716
Practice Address - Country:US
Practice Address - Phone:402-721-0090
Practice Address - Fax:402-721-9661
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1419363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47081915413Medicaid
1710125919Medicare NSC