Provider Demographics
NPI:1770687303
Name:HARDERSEN, JONATHAN DARREL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DARREL
Last Name:HARDERSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:BELMOND
Mailing Address - State:IA
Mailing Address - Zip Code:50421-1201
Mailing Address - Country:US
Mailing Address - Phone:515-327-2000
Mailing Address - Fax:515-327-2019
Practice Address - Street 1:403 1ST ST SE
Practice Address - Street 2:
Practice Address - City:BELMOND
Practice Address - State:IA
Practice Address - Zip Code:50421-1201
Practice Address - Country:US
Practice Address - Phone:515-327-2000
Practice Address - Fax:515-327-2019
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA440670040Medicare PIN
IA719260560Medicare PIN