Provider Demographics
NPI:1104626688
Name:TAGOAI, MARY SHEA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SHEA
Last Name:TAGOAI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SHEA
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8804 HOLMES ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-2512
Mailing Address - Country:US
Mailing Address - Phone:402-999-3854
Mailing Address - Fax:
Practice Address - Street 1:13906 GOLD CIR STE 103
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2336
Practice Address - Country:US
Practice Address - Phone:402-999-3854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant