Basic Information
| Provider Information | |||||||||
| NPI: | 1356359681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VASA | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 GRUNDMAN BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEBRASKA CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 684103320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028734242 | ||||||||
| FaxNumber: | 4028734227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 GRUNDMAN BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | NEBRASKA CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 684103320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028734242 | ||||||||
| FaxNumber: | 4028734227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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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 | 207Q00000X | 32225 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00862 | 01 | NE | BCBS | OTHER | 01-06562 | 01 | NE | UHC | OTHER | 6167213 | 05 | IA | MEDICAID | 10025323000 | 05 | NE | MEDICAID | 14882 | 01 | NE | MIDLAND'S CHOICE | OTHER | 500279401 | 05 | MS | MEDICAID |