Healthcare Provider Details

I. General information

NPI: 1225310204
Provider Name (Legal Business Name): NORTHWEST MISSOURI STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 UNIVERSITY DRIVE
MARYVILLE MO
64468
US

IV. Provider business mailing address

800 UNIVERSITY DRIVE
MARYVILLE MO
64468
US

V. Phone/Fax

Practice location:
  • Phone: 660-562-1313
  • Fax:
Mailing address:
  • Phone: 660-562-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW CANNELLA
Title or Position: HEAD ATHLETIC TRAINER
Credential: LAT
Phone: 660-562-1313