Healthcare Provider Details

I. General information

NPI: 1013243740
Provider Name (Legal Business Name): STEPHANIE LYNN FISHER GUSTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2009
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7308 S 142ND ST
OMAHA NE
68138-6804
US

IV. Provider business mailing address

7308 S 142ND ST
OMAHA NE
68138-6804
US

V. Phone/Fax

Practice location:
  • Phone: 402-717-4200
  • Fax: 402-717-4231
Mailing address:
  • Phone: 402-717-4200
  • Fax: 402-717-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number28505
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: