1649221110 NPI number — REBECCA D WITT PA-C

Table of content: REBECCA D WITT PA-C (NPI 1649221110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649221110 NPI number — REBECCA D WITT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITT
Provider First Name:
REBECCA
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649221110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3800 OLD CHENEY RD
Provider Second Line Business Mailing Address:
#101-331
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68516-5901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-758-5800
Provider Business Mailing Address Fax Number:
402-758-5809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17030 LAKESIDE HILLS PLZ
Provider Second Line Business Practice Location Address:
#102
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68130-2396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-758-5800
Provider Business Practice Location Address Fax Number:
402-758-5809
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1055 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 39024 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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