Healthcare Provider Details

I. General information

NPI: 1427513274
Provider Name (Legal Business Name): JEREMY MICHAEL HOSTETLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E CHERRY ST
SPRINGFIELD MO
65806-3401
US

IV. Provider business mailing address

961 GREASY CREEK RD
ELKLAND MO
65644-8240
US

V. Phone/Fax

Practice location:
  • Phone: 417-836-8553
  • Fax:
Mailing address:
  • Phone: 417-733-4890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2255A2300X
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: