Provider Demographics
NPI:1336183565
Name:JONASSEN, EDWARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:JONASSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1105
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-725-6532
Practice Address - Street 1:5419 N LOVINGTON HWY STE 31
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-9136
Practice Address - Country:US
Practice Address - Phone:575-392-3200
Practice Address - Fax:575-392-3212
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-49234207X00000X
NMMD2022-1534207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01272103Medicaid
COA104693Medicare PIN