Provider Demographics
NPI:1124042114
Name:FOX, MARIROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIROSE
Middle Name:
Last Name:FOX
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NE
Mailing Address - Zip Code:68361-0268
Mailing Address - Country:US
Mailing Address - Phone:402-759-4485
Mailing Address - Fax:402-759-4487
Practice Address - Street 1:1840 F ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NE
Practice Address - Zip Code:68361-2211
Practice Address - Country:US
Practice Address - Phone:402-759-4485
Practice Address - Fax:402-759-4487
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE207Q00000XMedicaid
NE278327Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NUMBE
NE207Q00000XMedicaid