Healthcare Provider Details

I. General information

NPI: 1528587813
Provider Name (Legal Business Name): PRAIRIE FOOT & ANKLE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1832 ASPEN LN STE A
GRAND ISLAND NE
68803-2487
US

IV. Provider business mailing address

PO BOX 5823
GRAND ISLAND NE
68802-5823
US

V. Phone/Fax

Practice location:
  • Phone: 308-646-0077
  • Fax: 308-646-0317
Mailing address:
  • Phone: 308-646-0077
  • Fax: 308-646-0317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: COREY S. BLACKBURN
Title or Position: PRESIDENT
Credential:
Phone: 308-646-0077