Healthcare Provider Details

I. General information

NPI: 1720934524
Provider Name (Legal Business Name): RAGHD JIHAD ALYATIM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DEPAUL DRIVE SUITE 205
BRIDGETON MO
63044
US

IV. Provider business mailing address

3845 JUNIATA ST APT 1
SAINT LOUIS MO
63116-4813
US

V. Phone/Fax

Practice location:
  • Phone: 314-218-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2026035620
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: