Healthcare Provider Details

I. General information

NPI: 1811991789
Provider Name (Legal Business Name): JOHN BECKENHAUER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EMILE @ 42ND ST
OMAHA NE
68198-0001
US

IV. Provider business mailing address

988102 NEBRASKA MEDICAL CTR
OMAHA NE
68198-8102
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number961
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number961
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: