Provider Demographics
NPI:1780282863
Name:PENDERGRASS, JARED ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:ALLEN
Last Name:PENDERGRASS
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 1:500 PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-2365
Mailing Address - Country:US
Mailing Address - Phone:417-678-7888
Mailing Address - Fax:
Practice Address - Street 1:500 PORTER AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2365
Practice Address - Country:US
Practice Address - Phone:417-678-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020009814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant