Healthcare Provider Details

I. General information

NPI: 1700423076
Provider Name (Legal Business Name): FAISAL MATAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MEXICO CT
SAINT PETERS MO
63376-5102
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 844-853-8937
  • Fax:
Mailing address:
  • Phone: 660-885-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2019042838
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: