Healthcare Provider Details

I. General information

NPI: 1679194583
Provider Name (Legal Business Name): KIARA PENDERGRAFT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIARA ANTUNA

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 MCINTOSH CIR
JOPLIN MO
64804-3643
US

IV. Provider business mailing address

1102 W 32ND ST
JOPLIN MO
64804-3503
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-14748
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberE-14748
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: