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General NPI Number Information
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NPI Number | 1679805105
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Entity Type | Individual
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Provider Name | JARED MATTHEW MCLISTER PAC
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Gender | Male
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Dates
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Enumeration Date | 02/09/2010
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Last Update Date | 01/28/2025
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Provider Practice Location Address
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Address Line | 2400 E CAPITOL DR
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City | APPLETON
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State | WI
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Zip | 54911-8728
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Country | US
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Telephone | 920-831-5050
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Fax | 920-738-6400
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Provider Business Mailing Address
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Address Line | 3 NEENAH CTR
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City | NEENAH
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State | WI
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Zip | 54956-3070
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Country | US
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Telephone | 920-830-5900
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Fax | 920-830-5910
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10698
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 4316-23
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License Number State | WI
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | MM2139118
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Identifier Type | OTHER
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Identifier State |
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Identifier Issuer | DEA
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