Basic Information
| Provider Information | |||||||||
| NPI: | 1699917492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEGNER | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17030 LAKESIDE HILLS PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023998550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17030 LAKESIDE HILLS PLZ | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681302396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023998550 | ||||||||
| FaxNumber: | 4023998455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2009 | ||||||||
| LastUpdateDate: | 04/28/2016 | ||||||||
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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 | 207X00000X | 28465 | NE | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100258006-00 | 05 | NE | MEDICAID | 1699917492 | 01 | NE | BCBS OF NE | OTHER | 1699917492 | 05 | IA | MEDICAID | 60258658 | 01 | NE | ARBOR HEALTH | OTHER | 1699917492 | 01 | IA | WELLMARK BCBS OF IA | OTHER | 470630101-13 | 05 | NE | MEDICAID |