Healthcare Provider Details

I. General information

NPI: 1780689083
Provider Name (Legal Business Name): ROGER WAYNE NUTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S 13TH ST STE1200
NORFOLK NE
68701-5792
US

IV. Provider business mailing address

710 S 13TH ST STE1200
NORFOLK NE
68701-5792
US

V. Phone/Fax

Practice location:
  • Phone: 402-370-4570
  • Fax:
Mailing address:
  • Phone: 402-370-4570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15072
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: