Provider Demographics
NPI:1952696379
Name:NEESEN, EVAN M (MD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:M
Last Name:NEESEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:933 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4626
Practice Address - Country:US
Practice Address - Phone:712-396-6111
Practice Address - Fax:712-396-7026
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NETEP6557207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE420680355-12Medicaid
IA1952696379Medicaid
NE420680355-12Medicaid