Provider Demographics
NPI:1881697944
Name:KEAN PUCCIONI, EMILY R (MD)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:R
Last Name:KEAN PUCCIONI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8577
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68108-0577
Mailing Address - Country:US
Mailing Address - Phone:402-397-7989
Mailing Address - Fax:402-397-8703
Practice Address - Street 1:10707 PACIFIC ST
Practice Address - Street 2:SUITE 101
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4762
Practice Address - Country:US
Practice Address - Phone:402-397-7989
Practice Address - Fax:402-393-7554
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE22781208800000X
NE22718208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098396Medicare ID - Type Unspecified
NEI18252Medicare UPIN