Provider Demographics
NPI:1710203054
Name:HASTINGS CONVENIENT CARE PC
Entity Type:Organization
Organization Name:HASTINGS CONVENIENT CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLEMENT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:402-463-6300
Mailing Address - Street 1:208 S BURLINGTON AVE
Mailing Address - Street 2:STE. 108
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5904
Mailing Address - Country:US
Mailing Address - Phone:402-463-6300
Mailing Address - Fax:402-834-0665
Practice Address - Street 1:208 S BURLINGTON AVE
Practice Address - Street 2:STE. 108
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5904
Practice Address - Country:US
Practice Address - Phone:402-463-6300
Practice Address - Fax:402-834-0665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
NE110737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025859600Medicaid
NE10692134OtherSTATE TAX ID
NENA1594Medicare PIN