Healthcare Provider Details

I. General information

NPI: 1093245235
Provider Name (Legal Business Name): NICHOLAS B KINKEAD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 HIGH ST
TECUMSEH NE
68450-2443
US

IV. Provider business mailing address

PO BOX 538
TECUMSEH NE
68450-0538
US

V. Phone/Fax

Practice location:
  • Phone: 402-335-2811
  • Fax: 402-335-2826
Mailing address:
  • Phone: 402-335-2811
  • Fax: 402-335-2826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2130
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: