Healthcare Provider Details

I. General information

NPI: 1508384363
Provider Name (Legal Business Name): RANDOLF J DUNN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W HICKORY ST
NEOSHO MO
64850-1705
US

IV. Provider business mailing address

PO BOX 3810
JOPLIN MO
64803-3810
US

V. Phone/Fax

Practice location:
  • Phone: 417-451-1234
  • Fax:
Mailing address:
  • Phone: 417-347-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017031227
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: