Provider Demographics
NPI:1336218478
Name:ELSASSER, GARY A (DC,CCST)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:ELSASSER
Suffix:
Gender:M
Credentials:DC,CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11906 I ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1244
Mailing Address - Country:US
Mailing Address - Phone:402-333-0352
Mailing Address - Fax:402-333-0731
Practice Address - Street 1:11906 I ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1244
Practice Address - Country:US
Practice Address - Phone:402-333-0352
Practice Address - Fax:402-333-0731
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE762111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE68021309000Medicaid
NE68021309000Medicaid
NET 40188Medicare UPIN
NE091510ELMedicare ID - Type Unspecified