Provider Demographics
NPI:1265401277
Name:PACKARD, CAROL MARY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:MARY
Last Name:PACKARD
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:OGALLALA
Mailing Address - State:NE
Mailing Address - Zip Code:69153-0026
Mailing Address - Country:US
Mailing Address - Phone:308-284-8421
Mailing Address - Fax:
Practice Address - Street 1:221 E 10TH ST
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-1425
Practice Address - Country:US
Practice Address - Phone:308-284-8421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-083450613Medicaid
273282PAMedicare ID - Type Unspecified
NE3950790001Medicare NSC
R80766Medicare UPIN