Basic Information
| Provider Information | |||||||||
| NPI: | 1003153636 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALTA | ||||||||
| FirstName: | CLAUDIA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126237250 | ||||||||
| FaxNumber: | 7126237257 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 SENATE AVE | ||||||||
| Address2: | STE. 105 | ||||||||
| City: | RED OAK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515661271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126237250 | ||||||||
| FaxNumber: | 7126237257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2013 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 002362 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 47068731710 | 05 | NE | MEDICAID |