Provider Demographics
NPI:1720319049
Name:PINK FERGUSON, KALENE LEE (PA-C)
Entity type:Individual
Prefix:
First Name:KALENE
Middle Name:LEE
Last Name:PINK FERGUSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21848 HILLANDALE RD
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-1703
Mailing Address - Country:US
Mailing Address - Phone:402-202-1724
Mailing Address - Fax:
Practice Address - Street 1:17645 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2034
Practice Address - Country:US
Practice Address - Phone:402-202-1724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant