Provider Demographics
NPI:1720018591
Name:MCINTOSH, MISTY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LYNN
Last Name:MCINTOSH
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 1:965 SOUTH 27TH STREET, SUITE D
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510
Mailing Address - Country:US
Mailing Address - Phone:402-477-3505
Mailing Address - Fax:
Practice Address - Street 1:965 SOUTH 27TH STREET, SUITE D
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510
Practice Address - Country:US
Practice Address - Phone:402-477-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004759363A00000X
NE1075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA229842468AMedicaid
GA229842468BMedicaid
GA229842468DMedicaid
GA229842468DMedicaid
GA97WCHSFMedicare ID - Type Unspecified