Provider Demographics
NPI:1720062458
Name:VAN WIE, JANA G (MD)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:G
Last Name:VAN WIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W FAIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4109
Mailing Address - Country:US
Mailing Address - Phone:308-382-8546
Mailing Address - Fax:308-381-8546
Practice Address - Street 1:3016 W FAIDLEY AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4109
Practice Address - Country:US
Practice Address - Phone:308-381-8546
Practice Address - Fax:308-381-8550
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16706207Q00000X
NE2801-16706174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP00885788OtherRR MEDICARE
NE1720062458OtherNPI
NE45359OtherBCBS
NE6501500001OtherMEDICARE DME PTAN
NE097552OtherGROUP PTAN
NE097552008OtherPTAN
NE1669781225OtherGROUP NPI
NE248833OtherMIDLANDS CHOICE
NE1033117015OtherGROUP NPI
NE10025894200Medicaid
NE1720062458OtherNPI
NED05208Medicare UPIN
NE097552OtherGROUP PTAN