Provider Demographics
NPI:1760623086
Name:DEGENHARDT, LYNDSEY G (PA)
Entity Type:Individual
Prefix:
First Name:LYNDSEY
Middle Name:G
Last Name:DEGENHARDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LYNDSEY
Other - Middle Name:G
Other - Last Name:HEESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1408 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-6912
Mailing Address - Country:US
Mailing Address - Phone:402-916-5665
Mailing Address - Fax:
Practice Address - Street 1:1408 VETERANS DR
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-6912
Practice Address - Country:US
Practice Address - Phone:402-916-5665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1434363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP01191169OtherRR MEDICARE
NENA1899004Medicare PIN