Provider Demographics
NPI:1245276948
Name:COUTURE, MARY (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COUTURE
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 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-4015
Mailing Address - Fax:402-559-8715
Practice Address - Street 1:988102 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8102
Practice Address - Country:US
Practice Address - Phone:402-559-4015
Practice Address - Fax:402-559-8715
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001535363A00000X
NE1056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
242918OtherMIDLANDS CHOICE
17293OtherWELLMARK BCBS
SD6827720Medicaid
17293OtherWELLMARK BCBS
112965Medicare PIN