Provider Demographics
NPI:1598713885
Name:LAUCK, KEVIN D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:D
Last Name:LAUCK
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:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NE
Mailing Address - Zip Code:68718-0357
Mailing Address - Country:US
Mailing Address - Phone:402-373-4341
Mailing Address - Fax:402-373-4344
Practice Address - Street 1:110 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NE
Practice Address - Zip Code:68718-4408
Practice Address - Country:US
Practice Address - Phone:402-373-4341
Practice Address - Fax:402-373-4344
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE277516Medicare ID - Type UnspecifiedPA
NEQ14026Medicare UPIN