Provider Demographics
NPI:1942925516
Name:KORTH, JONATHON RUSSELL
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:RUSSELL
Last Name:KORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46439 275 AVE
Mailing Address - Street 2:
Mailing Address - City:HUMPHREY
Mailing Address - State:NE
Mailing Address - Zip Code:68642-5003
Mailing Address - Country:US
Mailing Address - Phone:402-920-2926
Mailing Address - Fax:
Practice Address - Street 1:46439 275 AVE
Practice Address - Street 2:
Practice Address - City:HUMPHREY
Practice Address - State:NE
Practice Address - Zip Code:68642-5003
Practice Address - Country:US
Practice Address - Phone:402-920-2926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NE1942925516390200000X
NE2865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program