Basic Information
| Provider Information | |||||||||
| NPI: | 1811583941 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOWEN | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIESELHORST | ||||||||
| OtherFirstName: | SHELBY | ||||||||
| OtherMiddleName: | N | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | EMILE @ 42ND ST | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681980001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025594017 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2020 | ||||||||
| LastUpdateDate: | 12/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 113260 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.