Basic Information
| Provider Information | |||||||||
| NPI: | 1477591543 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCVEA | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | MD MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4920 S 30TH ST | ||||||||
| Address2: | STE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027344110 | ||||||||
| FaxNumber: | 4029915642 | ||||||||
| Practice Location | |||||||||
| Address1: | 4920 S 30TH ST | ||||||||
| Address2: | STE 103 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027344110 | ||||||||
| FaxNumber: | 4029915642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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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 | 207R00000X | 19808 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 19808 | NE | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 47054899017 | 05 | NE | MEDICAID |