Provider Demographics
NPI:1457429003
Name:OKOSUN, MELINDA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:MARIE
Last Name:OKOSUN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 S 70TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2471
Mailing Address - Country:US
Mailing Address - Phone:402-488-3322
Mailing Address - Fax:402-488-1172
Practice Address - Street 1:575 S 70TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2471
Practice Address - Country:US
Practice Address - Phone:402-488-3322
Practice Address - Fax:402-488-1172
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002447363AS0400X
NE1442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical