Healthcare Provider Details

I. General information

NPI: 1861444093
Provider Name (Legal Business Name): MARIAN K MEDUNA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 DODGE ST
OMAHA NE
68114-4108
US

IV. Provider business mailing address

PO BOX 2797
OMAHA NE
68103-2797
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-4000
  • Fax: 402-354-8469
Mailing address:
  • Phone: 402-354-4230
  • Fax: 402-354-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1698
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002851
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number082929
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: