Provider Demographics
NPI:1205944857
Name:HEDMAN, TANYA MARIE (OD)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:HEDMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 CROSS POINT DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-9711
Mailing Address - Country:US
Mailing Address - Phone:308-380-3989
Mailing Address - Fax:
Practice Address - Street 1:3501 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-8853
Practice Address - Country:US
Practice Address - Phone:308-381-5865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1246152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025252100Medicaid