Healthcare Provider Details

I. General information

NPI: 1104285865
Provider Name (Legal Business Name): MARY HALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16901 LAKESIDE HILLS CT ATTN: HOSPITAL MEDICINE
OMAHA NE
68130-2318
US

IV. Provider business mailing address

7261 MERCY RD
OMAHA NE
68124-2311
US

V. Phone/Fax

Practice location:
  • Phone: 855-524-4001
  • Fax: 402-717-7340
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2002
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number081276
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: