Healthcare Provider Details

I. General information

NPI: 1285523530
Provider Name (Legal Business Name): SHEA MIOTKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 WALNUT DR
WAYNE NE
68787-1451
US

IV. Provider business mailing address

1120 MAIN ST
WAYNE NE
68787-1120
US

V. Phone/Fax

Practice location:
  • Phone: 402-604-1959
  • Fax:
Mailing address:
  • Phone: 402-604-1959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: