Healthcare Provider Details

I. General information

NPI: 1720469778
Provider Name (Legal Business Name): MARAN AVERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S 16TH ST SUITE 405
LINCOLN NE
68502-3796
US

IV. Provider business mailing address

2222 S 16TH ST SUITE 405
LINCOLN NE
68502-3796
US

V. Phone/Fax

Practice location:
  • Phone: 402-474-3704
  • Fax: 402-474-3748
Mailing address:
  • Phone: 402-474-3704
  • Fax: 402-474-3748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1922
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: