Healthcare Provider Details

I. General information

NPI: 1760830335
Provider Name (Legal Business Name): MATTHEW J ROESNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 BETTEN DR
CRETE NE
68333-3084
US

IV. Provider business mailing address

PO BOX 220
CRETE NE
68333-0220
US

V. Phone/Fax

Practice location:
  • Phone: 402-826-2102
  • Fax:
Mailing address:
  • Phone: 402-826-2102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2016
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: