Provider Demographics
NPI:1013163963
Name:NYBAKKEN, MARY M (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:NYBAKKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:983255 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-3255
Mailing Address - Country:US
Mailing Address - Phone:402-559-4500
Mailing Address - Fax:402-559-9416
Practice Address - Street 1:5225 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7927
Practice Address - Country:US
Practice Address - Phone:701-417-2575
Practice Address - Fax:701-417-2535
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL10954207Q00000X
NE7357207V00000X
ND11358207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12083Medicaid
NDN6252Medicare PIN