Basic Information
| Provider Information | |||||||||
| NPI: | 1811991789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKENHAUER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | EMILE @ 42ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681980001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025595000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 961 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 961 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970030785 | 01 | NE | RAILROAD MEDICARE | OTHER | 47081304012 | 05 | NE | MEDICAID | 37830 | 01 | NE | BCBS | OTHER | 68154A018 | 01 | NE | TRICARE | OTHER |