Provider Demographics
NPI:1558377580
Name:WHALEN, MICHAEL J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:WHALEN
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 1:2725 S 144TH ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5243
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0852
Practice Address - Street 1:2725 S 144TH ST
Practice Address - Street 2:SUITE 212
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5243
Practice Address - Country:US
Practice Address - Phone:402-637-0800
Practice Address - Fax:402-637-0852
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE556363A00000X
IA001184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38528OtherBCBS OF NEBRASKA
IAP00418185OtherMEDICARE RAILROAD
IAI6061Medicare PIN
NE38528OtherBCBS OF NEBRASKA
R72776Medicare UPIN