Provider Demographics
NPI:1679100655
Name:KEBLESH, HANH NGUYEN (PA)
Entity Type:Individual
Prefix:
First Name:HANH
Middle Name:NGUYEN
Last Name:KEBLESH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 N 161ST AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-6429
Mailing Address - Country:US
Mailing Address - Phone:402-541-4378
Mailing Address - Fax:
Practice Address - Street 1:2429 M ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-2715
Practice Address - Country:US
Practice Address - Phone:402-731-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1159372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty