Healthcare Provider Details

I. General information

NPI: 1487589305
Provider Name (Legal Business Name): MADISON BOGART FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2026
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 S BISHOP AVE STE C
ROLLA MO
65401-4320
US

IV. Provider business mailing address

10425 S HIGHWAY 68
SAINT JAMES MO
65559-6103
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-9000
  • Fax:
Mailing address:
  • Phone: 573-263-5765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2026023503
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: