Healthcare Provider Details

I. General information

NPI: 1497782106
Provider Name (Legal Business Name): RICKY A POWELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 OLD BALLAS RD STE 100
SAINT LOUIS MO
63141-7083
US

IV. Provider business mailing address

675 OLD BALLAS RD STE 100
SAINT LOUIS MO
63141-7083
US

V. Phone/Fax

Practice location:
  • Phone: 314-733-9009
  • Fax:
Mailing address:
  • Phone: 314-733-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number114408
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: