Healthcare Provider Details

I. General information

NPI: 1073472627
Provider Name (Legal Business Name): WILLIAM RANDOLPH JONES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 S 30TH ST STE 103
OMAHA NE
68107-1656
US

IV. Provider business mailing address

4920 S 30TH ST STE 103
OMAHA NE
68107-1656
US

V. Phone/Fax

Practice location:
  • Phone: 402-734-4110
  • Fax: 402-734-3990
Mailing address:
  • Phone: 402-734-4110
  • Fax: 402-734-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: