Basic Information
| Provider Information | |||||||||
| NPI: | 1073247748 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CREEVAN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5500 PINE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685163389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024898888 | ||||||||
| FaxNumber: | 4024211945 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 PINE LAKE RD | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685163389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024898888 | ||||||||
| FaxNumber: | 4024211945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2022 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2777 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.