Healthcare Provider Details

I. General information

NPI: 1255440319
Provider Name (Legal Business Name): KEVIN K WYCOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W 14TH ST
HASTINGS NE
68901-3046
US

IV. Provider business mailing address

PO BOX 968
HASTINGS NE
68902-0968
US

V. Phone/Fax

Practice location:
  • Phone: 402-462-8456
  • Fax: 402-463-9697
Mailing address:
  • Phone: 402-462-8456
  • Fax: 402-463-9697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13772
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: