Provider Demographics
NPI:1568412641
Name:WIEKAMP, JULIE MARIE (PA)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:MARIE
Last Name:WIEKAMP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:EIHUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3540 VILLAGE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4706
Mailing Address - Country:US
Mailing Address - Phone:402-420-7113
Mailing Address - Fax:402-328-8314
Practice Address - Street 1:3540 VILLAGE DR STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4706
Practice Address - Country:US
Practice Address - Phone:402-420-7113
Practice Address - Fax:402-328-8314
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1234363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEQ63021Medicare UPIN