Healthcare Provider Details

I. General information

NPI: 1174918445
Provider Name (Legal Business Name): LYNN SWAFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 NW PLATTE RD
RIVERSIDE MO
64150-9601
US

IV. Provider business mailing address

1805 NW PLATTE RD
RIVERSIDE MO
64150-9601
US

V. Phone/Fax

Practice location:
  • Phone: 816-472-0400
  • Fax:
Mailing address:
  • Phone: 816-472-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2014043323
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: