Healthcare Provider Details

I. General information

NPI: 1396760476
Provider Name (Legal Business Name): DAVID DOUGLAS P.A.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 COWAN DR
LEBANON MO
65536-4629
US

IV. Provider business mailing address

PO BOX 517
MARSHFIELD MO
65706-0517
US

V. Phone/Fax

Practice location:
  • Phone: 417-532-2805
  • Fax: 417-532-2865
Mailing address:
  • Phone: 417-849-5072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2004022171
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: