Provider Demographics
NPI:1003866237
Name:EXSTROM, BRYCE A (PA)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:A
Last Name:EXSTROM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:350 W 23RD ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2592
Mailing Address - Country:US
Mailing Address - Phone:402-721-8800
Mailing Address - Fax:402-753-6096
Practice Address - Street 1:350 W 23RD ST
Practice Address - Street 2:SUITE D
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2592
Practice Address - Country:US
Practice Address - Phone:402-721-8800
Practice Address - Fax:402-753-6096
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE93363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NER81501Medicare UPIN
NE276446Medicare ID - Type Unspecified
NE276476Medicare ID - Type Unspecified