Healthcare Provider Details

I. General information

NPI: 1134606858
Provider Name (Legal Business Name): MATTHEW GENE PULLEY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OAK GROVE RD
POPLAR BLUFF MO
63901-1573
US

IV. Provider business mailing address

PO BOX 708760
SANDY UT
84070-8760
US

V. Phone/Fax

Practice location:
  • Phone: 573-776-2000
  • Fax:
Mailing address:
  • Phone: 801-352-9500
  • Fax: 801-352-7976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017813
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2018004234
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: