1760577035 NPI number — SHIRLEY O MOHR BURT APRN

Table of content: SHIRLEY O MOHR BURT APRN (NPI 1760577035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760577035 NPI number — SHIRLEY O MOHR BURT APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOHR BURT
Provider First Name:
SHIRLEY
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760577035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 S 48TH ST
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68506-1275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-483-3333
Provider Business Mailing Address Fax Number:
402-483-3297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 S 48TH ST
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68506-1275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-483-3333
Provider Business Practice Location Address Fax Number:
402-483-3297
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  110178 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47084496100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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