Basic Information
| Provider Information | |||||||||
| NPI: | 1073695037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRIESEN | ||||||||
| FirstName: | CLAYTON | ||||||||
| MiddleName: | JOSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7440 SOUTH 91ST STREET | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024896555 | ||||||||
| FaxNumber: | 4023283770 | ||||||||
| Practice Location | |||||||||
| Address1: | 3515 RICHMOND CIRCLE | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688034965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3083818636 | ||||||||
| FaxNumber: | 3083818622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 10/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22964 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 22964 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 47070592301 | 05 | NE | MEDICAID | 10026072300 | 05 | NE | MEDICAID | 47070592300 | 05 | NE | MEDICAID | 47070592305 | 05 | NE | MEDICAID | 10026072500 | 05 | NE | MEDICAID | 47070592302 | 05 | NE | MEDICAID | 0401410 | 05 | IA | MEDICAID | 200536770A | 05 | KS | MEDICAID | 2401410 | 05 | IA | MEDICAID | 10026072400 | 05 | NE | MEDICAID | 47070592313 | 05 | NE | MEDICAID | 47070592306 | 05 | NE | MEDICAID |