Provider Demographics
NPI:1528587813
Name:PRAIRIE FOOT & ANKLE PC
Entity Type:Organization
Organization Name:PRAIRIE FOOT & ANKLE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-646-0077
Mailing Address - Street 1:PO BOX 5823
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5823
Mailing Address - Country:US
Mailing Address - Phone:308-646-0077
Mailing Address - Fax:308-646-0317
Practice Address - Street 1:1932 ASPEN CIR STE A
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2474
Practice Address - Country:US
Practice Address - Phone:308-646-0077
Practice Address - Fax:308-646-0317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47062497913Medicaid