Healthcare Provider Details

I. General information

NPI: 1235824418
Provider Name (Legal Business Name): JACOB WINGATE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16901 LAKESIDE HILLS CT
OMAHA NE
68130-2318
US

IV. Provider business mailing address

16901 LAKESIDE HILLS CT
OMAHA NE
68130-2318
US

V. Phone/Fax

Practice location:
  • Phone: 402-717-8111
  • Fax:
Mailing address:
  • Phone: 402-717-8111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3183
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: