Basic Information
| Provider Information | |||||||||
| NPI: | 1063462208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NASIR | ||||||||
| FirstName: | LAETH | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1319 LEAVENWORTH ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681023215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027170420 | ||||||||
| FaxNumber: | 4027176042 | ||||||||
| Practice Location | |||||||||
| Address1: | 988095 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025599800 | ||||||||
| FaxNumber: | 4025599840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18597 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 47078557507 | 05 | NE | MEDICAID |