Basic Information
| Provider Information | |||||||||
| NPI: | 1073891628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WACHAL | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 N 190TH PLZ | ||||||||
| Address2: | STE. 1100 | ||||||||
| City: | ELKHORN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680223913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028151700 | ||||||||
| FaxNumber: | 4028151959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2011 | ||||||||
| LastUpdateDate: | 09/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 11278 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 47068731799 | 05 | NE | MEDICAID | 10026301600 | 05 | NE | MEDICAID | 10026480100 | 05 | NE | MEDICAID | 1073891628 | 05 | IA | MEDICAID |