Healthcare Provider Details

I. General information

NPI: 1881669075
Provider Name (Legal Business Name): MARTIN N KATAMBWA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 N 22ND ST
BLAIR NE
68008-1128
US

IV. Provider business mailing address

4502 N 206TH ST
ELKHORN NE
68022-6992
US

V. Phone/Fax

Practice location:
  • Phone: 402-426-4611
  • Fax: 402-426-4642
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085004591
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2003004599
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2036
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: