Healthcare Provider Details

I. General information

NPI: 1700859519
Provider Name (Legal Business Name): LISA M BECK MPA S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17675 WELCH PLZ
OMAHA NE
68135-3551
US

IV. Provider business mailing address

2808 S 80TH AVE STE 110
OMAHA NE
68124-3253
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-7610
  • Fax: 402-354-7615
Mailing address:
  • Phone: 402-504-3707
  • Fax: 402-504-3714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number813
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number813
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: