Provider Demographics
NPI:1336322866
Name:LIES, JOLENE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JOLENE
Middle Name:MARIE
Last Name:LIES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JOLENE
Other - Middle Name:MARIE
Other - Last Name:LUKASIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5005 S 153RD ST STE 100
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-5070
Practice Address - Country:US
Practice Address - Phone:402-717-1255
Practice Address - Fax:402-818-1924
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA111296363A00000X
NE672363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NES15683Medicare UPIN