Provider Demographics
NPI:1659907475
Name:ROUGHEAD, WILLIAM A JR (PAC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:ROUGHEAD
Suffix:JR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:A
Other - Last Name:ROUGHEAD
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:2727 S 144TH ST STE 240
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5201
Mailing Address - Country:US
Mailing Address - Phone:402-609-1200
Mailing Address - Fax:402-609-1220
Practice Address - Street 1:2727 S 144TH ST STE 240
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5201
Practice Address - Country:US
Practice Address - Phone:402-609-1200
Practice Address - Fax:402-609-1220
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant