=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649684184
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN BARRETT WALDREP PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2014
-----------------------------------------------------
Last Update Date | 03/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7120 S 69TH ST STE 101A
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68516-3868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-520-8955
-----------------------------------------------------
Fax | 833-471-5257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7120 S 69TH ST STE 101A
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68516-3868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-520-8955
-----------------------------------------------------
Fax | 833-471-5257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------