Provider Demographics
NPI:1154442507
Name:WIEBUSCH, LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:
Last Name:WIEBUSCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 PINE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3389
Mailing Address - Country:US
Mailing Address - Phone:402-489-8888
Mailing Address - Fax:402-421-1945
Practice Address - Street 1:5500 PINE LAKE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3389
Practice Address - Country:US
Practice Address - Phone:402-489-8888
Practice Address - Fax:402-421-1945
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25807208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE545167OtherCOVENTRY HEALTH CARE
NE45237OtherBCBS
NE093432001Medicare UPIN