Provider Demographics
NPI:1437236403
Name:STUBERG, WAYNE (PHD, PT)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:STUBERG
Suffix:
Gender:M
Credentials:PHD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:985459 NEBRASKA MED CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-5450
Mailing Address - Country:US
Mailing Address - Phone:402-559-8943
Mailing Address - Fax:
Practice Address - Street 1:444 S 44TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-3727
Practice Address - Country:US
Practice Address - Phone:402-559-8943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025288900Medicaid
279652Medicare ID - Type Unspecified
NE10025288900Medicaid