Healthcare Provider Details

I. General information

NPI: 1982105425
Provider Name (Legal Business Name): MOD DERMATOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16910 FRANCES ST
OMAHA NE
68130-2398
US

IV. Provider business mailing address

16910 FRANCES ST
OMAHA NE
68130-2398
US

V. Phone/Fax

Practice location:
  • Phone: 402-505-8777
  • Fax: 402-933-7767
Mailing address:
  • Phone: 402-505-8777
  • Fax: 402-933-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number28493
License Number StateNE

VIII. Authorized Official

Name: ALAINA PATERA
Title or Position: PRACTICE MANAGER
Credential: MBA
Phone: 402-505-8777