Healthcare Provider Details

I. General information

NPI: 1932518610
Provider Name (Legal Business Name): KEVIN WITCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S 70TH ST
LINCOLN NE
68506-1569
US

IV. Provider business mailing address

1650 S 70TH ST
LINCOLN NE
68506-1569
US

V. Phone/Fax

Practice location:
  • Phone: 402-261-6764
  • Fax:
Mailing address:
  • Phone: 402-261-6764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number111656
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: