Provider Demographics
NPI:1265480537
Name:GUTHMILLER, SALLY J (PA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:GUTHMILLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:J
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2725 S 144TH ST STE 212
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5253
Mailing Address - Country:US
Mailing Address - Phone:402-637-0800
Mailing Address - Fax:402-637-0808
Practice Address - Street 1:2725 S 144TH ST STE 212
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5253
Practice Address - Country:US
Practice Address - Phone:402-637-0800
Practice Address - Fax:402-637-0808
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076029363A00000X
NE997363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP66266Medicare UPIN
NE277432Medicare ID - Type Unspecified