Provider Demographics
NPI:1801080734
Name:TOLLEFSEN, GREGORY RYAN (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:RYAN
Last Name:TOLLEFSEN
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2810 W 35TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2909
Mailing Address - Country:US
Mailing Address - Phone:308-865-2570
Mailing Address - Fax:
Practice Address - Street 1:2810 W 35TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2909
Practice Address - Country:US
Practice Address - Phone:308-865-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1644363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant