Provider Demographics
NPI:1760472039
Name:PETERSON, WALLACE CARY JR (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:CARY
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 TIGER LILY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5587
Mailing Address - Country:US
Mailing Address - Phone:402-420-7000
Mailing Address - Fax:402-420-6969
Practice Address - Street 1:4101 TIGER LILY RD STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5587
Practice Address - Country:US
Practice Address - Phone:402-420-7000
Practice Address - Fax:402-420-6969
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16442207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200000870AMedicaid
NE32276OtherBCBS
NE3600017OtherUHC
NE1242OtherMIDLANDS CHOICE
NE91186278513Medicaid
NE91186278513Medicaid
NE269752Medicare PIN
KS200000870AMedicaid