Provider Demographics
NPI:1881669075
Name:KATAMBWA, MARTIN N (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:N
Last Name:KATAMBWA
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 1:4502 N 206TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-6992
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:812 N 22ND ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:NE
Practice Address - Zip Code:68008-1128
Practice Address - Country:US
Practice Address - Phone:402-426-4611
Practice Address - Fax:402-426-4642
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004591363AM0700X
MO2003004599363AM0700X
NE2036363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP65811Medicare UPIN
MO000097281Medicare ID - Type Unspecified