Provider Demographics
NPI:1043230287
Name:SUTPHEN, JAMES A (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:SUTPHEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 MERCY RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3410 N 156TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-2020
Practice Address - Country:US
Practice Address - Phone:402-614-1258
Practice Address - Fax:402-614-5733
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1218363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38050OtherBCBS
P00289237Medicare ID - Type Unspecified
Q62592Medicare UPIN
NE38050OtherBCBS