Healthcare Provider Details

I. General information

NPI: 1841474244
Provider Name (Legal Business Name): JASON ROBERT MCCOY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 01/08/2023
Certification Date: 01/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N 66TH ST
LINCOLN NE
68505-2402
US

IV. Provider business mailing address

110 N 66TH ST
LINCOLN NE
68505-2402
US

V. Phone/Fax

Practice location:
  • Phone: 402-325-8950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1594
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1501483
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: