Healthcare Provider Details

I. General information

NPI: 1700749694
Provider Name (Legal Business Name): ALYSSA GAFNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N BENTON AVE
SPRINGFIELD MO
65802-3712
US

IV. Provider business mailing address

900 N BENTON AVE
SPRINGFIELD MO
65802-3712
US

V. Phone/Fax

Practice location:
  • Phone: 417-873-7879
  • Fax:
Mailing address:
  • Phone: 417-873-7879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1239990
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: