Basic Information
| Provider Information | |||||||||
| NPI: | 1316168628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENTZER | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WARDYN | ||||||||
| OtherFirstName: | GINA | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7440 S 91ST ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024896555 | ||||||||
| FaxNumber: | 4023283770 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 Q ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685033609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023284572 | ||||||||
| FaxNumber: | 4024210946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 27190 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 35.095058 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10026072500 | 05 | NE | MEDICAID | 10026072000 | 05 | NE | MEDICAID | 10026072600 | 05 | NE | MEDICAID | 10026072300 | 05 | NE | MEDICAID | FW0491388 | 01 | NE | DEA | OTHER | 10026072200 | 05 | NE | MEDICAID | 10026072400 | 05 | NE | MEDICAID |