Healthcare Provider Details

I. General information

NPI: 1669581708
Provider Name (Legal Business Name): GLORIA MILBOURN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 MAIN STREET
LOUISVILLE NE
68037
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-9050
  • Fax: 402-234-5202
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1070
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: