Provider Demographics
NPI:1215568175
Name:GREVENGOED, MIKAYLA K (PA)
Entity Type:Individual
Prefix:MRS
First Name:MIKAYLA
Middle Name:K
Last Name:GREVENGOED
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:K
Other - Last Name:LOCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 24607
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124
Mailing Address - Country:US
Mailing Address - Phone:402-955-5400
Mailing Address - Fax:402-955-3674
Practice Address - Street 1:8200 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114
Practice Address - Country:US
Practice Address - Phone:402-955-5400
Practice Address - Fax:402-955-4364
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA115612363A00000X
NE2429363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical