Provider Demographics
NPI:1427031764
Name:MOODY, MARY K (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:MOODY
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 431
Mailing Address - Street 2:
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-0431
Mailing Address - Country:US
Mailing Address - Phone:308-432-4441
Mailing Address - Fax:308-432-2130
Practice Address - Street 1:825 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-9400
Practice Address - Country:US
Practice Address - Phone:308-432-4441
Practice Address - Fax:308-432-2130
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE276564Medicare ID - Type UnspecifiedPERFORMING PROVIDER #
NES55541Medicare UPIN
NEP00072221Medicare ID - Type UnspecifiedRAILROAD MEDICARE #