Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 111149 | NE |
Y | 363L00000X | Nurse Practitioner | A149479 | IA |
N | 363LF0000X | Nurse Practitioner - Family Medicine | 111149 | NE |
N | 363LF0000X | Nurse Practitioner - Family Medicine | A149479 | IA |
N | 363LP2300X | Nurse Practitioner - Primary Care | 111149 | NE |
NPI | 1093028805 |
---|---|
Provider Name | Mrs. Athena C Fertig |
First Address | Omaha, NE 68131-3003 |
Second Address | Omaha, NE 68131-3003 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2010 |
Last Update Date | 14/02/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
10025024300 | (05) | NE |
10025024400 | (05) | NE |
47279 | BCBS NE (01) | NE |
48515 | BCBS NE (PLH) (01) | NE |