Basic Information
| Provider Information | |||||||||
| NPI: | 1659907475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUGHEAD | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROUGHEAD | ||||||||
| OtherFirstName: | WILLIAM | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2727 S 144TH ST STE 240 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681445201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026091200 | ||||||||
| FaxNumber: | 4026091220 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 S 144TH ST STE 240 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681445201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026091200 | ||||||||
| FaxNumber: | 4026091220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2020 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2466 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.