Healthcare Provider Details

I. General information

NPI: 1053601716
Provider Name (Legal Business Name): CEPHAS PANIAMOGAN FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3202 MILLER ST
BETHANY MO
64424-2713
US

IV. Provider business mailing address

16027 LOCUST ST APT 5
EAGLEVILLE MO
64442-7130
US

V. Phone/Fax

Practice location:
  • Phone: 660-425-3154
  • Fax:
Mailing address:
  • Phone: 660-867-5111
  • Fax: 660-425-2366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2011007027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: