Healthcare Provider Details

I. General information

NPI: 1760954952
Provider Name (Legal Business Name): MATTHEW DAVID TELMER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROGRESS POINT PKWY STE 206
O FALLON MO
63368-2207
US

IV. Provider business mailing address

20 PROGRESS POINT PKWY STE 206
O FALLON MO
63368-2207
US

V. Phone/Fax

Practice location:
  • Phone: 636-344-1073
  • Fax:
Mailing address:
  • Phone: 636-344-1073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018034196
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2018034196
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: