MEDICARE: DUSTIN JAMBORETZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1720442387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN JAMBORETZ

Provider Business Mailing Address
First Line	:	7801 NE 74TH PL
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64158-1269
Country	:	US
Telephone Number	:	816-668-8915
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 DES PERES RD STE 210
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63131-2062
Country	:	US
Telephone Number	:	314-896-4263
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2016
Last Update Date	:	01/25/2020

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Directions to “ DUSTIN JAMBORETZ ” Practice Location

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