Provider Demographics
NPI:1649684184
Name:WALDREP, JOHN BARRETT (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BARRETT
Last Name:WALDREP
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7120 S 69TH ST STE 101A
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3868
Mailing Address - Country:US
Mailing Address - Phone:402-520-8955
Mailing Address - Fax:833-471-5257
Practice Address - Street 1:7120 S 69TH ST STE 101A
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3868
Practice Address - Country:US
Practice Address - Phone:402-520-8955
Practice Address - Fax:833-471-5257
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE096938010Medicare PIN