=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700859519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA M BECK MPA S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2006
-----------------------------------------------------
Last Update Date | 02/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17675 WELCH PLZ
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68135-3551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-354-7610
-----------------------------------------------------
Fax | 402-354-7615
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2808 S 80TH AVE STE 110
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68124-3253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-504-3707
-----------------------------------------------------
Fax | 402-504-3714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 813
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 813
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------