Basic Information
| Provider Information | |||||||||
| NPI: | 1740695899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KILSTROM | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2797 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681032797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023544230 | ||||||||
| FaxNumber: | 4023546171 | ||||||||
| Practice Location | |||||||||
| Address1: | 933 E PIERCE ST | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123966111 | ||||||||
| FaxNumber: | 7123967026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA09172 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 081384 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1740695899 | 05 | IA | MEDICAID | 420680355-12 | 05 | NE | MEDICAID |