Provider Demographics
NPI:1265971865
Name:CONDREN, JACOB (JAKE) WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB (JAKE)
Middle Name:WILLIAM
Last Name:CONDREN
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 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-326-6000
Mailing Address - Fax:417-328-6338
Practice Address - Street 1:1155 W PARKVIEW ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-8279
Practice Address - Country:US
Practice Address - Phone:417-777-2663
Practice Address - Fax:417-777-2666
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant