Basic Information
| Provider Information | |||||||||
| NPI: | 1215568175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOCKE | ||||||||
| FirstName: | MIKAYLA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24607 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681240607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029555400 | ||||||||
| FaxNumber: | 4029553674 | ||||||||
| Practice Location | |||||||||
| Address1: | 8200 DODGE ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029554360 | ||||||||
| FaxNumber: | 4029554364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2020 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2429 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.