Provider Demographics
NPI:1699238378
Name:LUSIENSKI, MEGAN M (PA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:LUSIENSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:THROENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10707 PACIFIC ST STE 101
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4762
Mailing Address - Country:US
Mailing Address - Phone:402-397-7989
Mailing Address - Fax:402-397-8703
Practice Address - Street 1:10707 PACIFIC ST STE 101
Practice Address - Street 2:
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:402-397-8703
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47077934913Medicaid
NE2324OtherNE LICENSE