Healthcare Provider Details

I. General information

NPI: 1467833871
Provider Name (Legal Business Name): REGAN MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 S MAIN ST STE D
JOPLIN MO
64804-2678
US

IV. Provider business mailing address

2613 S MAIN ST STE D
JOPLIN MO
64804-2678
US

V. Phone/Fax

Practice location:
  • Phone: 417-553-7920
  • Fax:
Mailing address:
  • Phone: 417-553-7920
  • Fax: 877-464-5922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2019006014
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number76805
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: