Healthcare Provider Details

I. General information

NPI: 1548866064
Provider Name (Legal Business Name): JOSE GARY NADALA CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S 16TH ST STE 410
LINCOLN NE
68502-3785
US

IV. Provider business mailing address

2222 S 16TH ST STE 410
LINCOLN NE
68502-3785
US

V. Phone/Fax

Practice location:
  • Phone: 402-474-1511
  • Fax: 402-474-1611
Mailing address:
  • Phone: 402-474-1511
  • Fax: 402-474-1611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER WITZKE-KONRADI
Title or Position: MANAGER
Credential:
Phone: 402-474-1511