Provider Demographics
NPI:1366424863
Name:ANANIA BACKSTROM, CECILIA (PA-C)
Entity type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:ANANIA BACKSTROM
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:PO BOX 641850
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-7850
Mailing Address - Country:US
Mailing Address - Phone:402-572-3535
Mailing Address - Fax:402-572-2688
Practice Address - Street 1:6901 N 72ND ST
Practice Address - Street 2:SUITE 2244
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1709
Practice Address - Country:US
Practice Address - Phone:402-572-3535
Practice Address - Fax:402-572-2688
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00317363A00000X
NE1294363A00000X
IA1875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100342400AMedicaid
KS100342400AMedicaid
KS35301BAMedicare ID - Type Unspecified