Healthcare Provider Details

I. General information

NPI: 1508620733
Provider Name (Legal Business Name): AMBERLY TAITE EVERSOLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E WALNUT LAWN ST STE 201
SPRINGFIELD MO
65807-7865
US

IV. Provider business mailing address

PO BOX 505673
SAINT LOUIS MO
63150-5673
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4450
  • Fax: 417-269-8333
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2024004719
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: