Provider Demographics
NPI:1720469778
Name:AVERY, MARAN
Entity Type:Individual
Prefix:
First Name:MARAN
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 S 16TH ST
Mailing Address - Street 2:SUITE 405
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3796
Mailing Address - Country:US
Mailing Address - Phone:402-474-3704
Mailing Address - Fax:402-474-3748
Practice Address - Street 1:2222 S 16TH ST
Practice Address - Street 2:SUITE 405
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3796
Practice Address - Country:US
Practice Address - Phone:402-474-3704
Practice Address - Fax:402-474-3748
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1922363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical