Healthcare Provider Details

I. General information

NPI: 1922073634
Provider Name (Legal Business Name): SAMUEL J DOSTAL PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 09/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 A ST STE 100
LINCOLN NE
68510-4120
US

IV. Provider business mailing address

6900 A ST
LINCOLN NE
68510-4120
US

V. Phone/Fax

Practice location:
  • Phone: 402-436-2000
  • Fax: 402-436-2090
Mailing address:
  • Phone: 402-436-2000
  • Fax: 402-434-2691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1217
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1217
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: