Provider Demographics
NPI:1386089332
Name:DELLUTRI, MARNIE ELIZBETH JEAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARNIE
Middle Name:ELIZBETH JEAN
Last Name:DELLUTRI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARNIE
Other - Middle Name:ELIZABETH JEAN
Other - Last Name:THRASHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
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:402-393-7554
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:2013-05-03
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NE1728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47077934913Medicaid