Provider Demographics
NPI:1871951327
Name:KEANE, MINDY (PA-C)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:KEANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8005 FARNAM DR STE 305
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3426
Mailing Address - Country:US
Mailing Address - Phone:402-390-4111
Mailing Address - Fax:402-390-4115
Practice Address - Street 1:8005 FARNAM DR STE 305
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3426
Practice Address - Country:US
Practice Address - Phone:402-390-4111
Practice Address - Fax:402-390-4115
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731742Medicaid
IA1871954327Medicaid
NE47068731751Medicaid