Basic Information
| Provider Information | |||||||||
| NPI: | 1508843681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WORDEKEMPER | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 EDMUNDSON PL | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123964340 | ||||||||
| FaxNumber: | 7123964180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 05/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1477 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 001158 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 47068731785 | 05 | NE | MEDICAID | 47068731712 | 05 | NE | MEDICAID | 47068731749 | 05 | NE | MEDICAID | 10026480100 | 05 | NE | MEDICAID | 47068731734 | 05 | NE | MEDICAID | 10025464000 | 05 | NE | MEDICAID | 47068731741 | 05 | NE | MEDICAID | 47068731777 | 05 | NE | MEDICAID | 1508813681 | 05 | IA | MEDICAID |