Healthcare Provider Details

I. General information

NPI: 1629321161
Provider Name (Legal Business Name): GILBERT MATTHEW COMOLA AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 04/17/2025
Certification Date: 03/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV SURG UROLOGY, STE 11C
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-8200
  • Fax: 314-454-5244
Mailing address:
  • Phone: 314-362-8200
  • Fax: 314-454-5244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2022021386
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: