Provider Demographics
NPI:1972218790
Name:MCCOY, MARY BERNADETTE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BERNADETTE
Last Name:MCCOY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3512 S 105TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3606
Mailing Address - Country:US
Mailing Address - Phone:319-290-2158
Mailing Address - Fax:
Practice Address - Street 1:4350 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1017
Practice Address - Country:US
Practice Address - Phone:402-552-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE143927367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered