Provider Demographics
NPI:1932195161
Name:HYDE, MIA J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:J
Last Name:HYDE
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 1:3016 W. FAIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803
Mailing Address - Country:US
Mailing Address - Phone:308-381-8546
Mailing Address - Fax:308-381-8550
Practice Address - Street 1:816 22ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2226
Practice Address - Country:US
Practice Address - Phone:308-865-2263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE562363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-077225812Medicaid
NER81512Medicare UPIN
NE272911HYMedicare PIN