Healthcare Provider Details

I. General information

NPI: 1821203340
Provider Name (Legal Business Name): CAROLYN PEARL PRATER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S MAIDEN LN
JOPLIN MO
64801-3084
US

IV. Provider business mailing address

4301 DONIPHAN DR
NEOSHO MO
64850-9120
US

V. Phone/Fax

Practice location:
  • Phone: 417-659-9100
  • Fax: 417-659-9101
Mailing address:
  • Phone: 417-451-9450
  • Fax: 417-451-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number106608
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: