Basic Information
| Provider Information | |||||||||
| NPI: | 1245276948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COUTURE | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025594015 | ||||||||
| FaxNumber: | 4025598715 | ||||||||
| Practice Location | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025594015 | ||||||||
| FaxNumber: | 4025598715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 06/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001535 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1056 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 242918 | 01 | MIDLANDS CHOICE | OTHER | 17293 | 01 | WELLMARK BCBS | OTHER | 6827720 | 05 | SD | MEDICAID |