Healthcare Provider Details

I. General information

NPI: 1841255452
Provider Name (Legal Business Name): MARTHA HURST DEADY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JOHN COCHRAN VAMC 915 NORTH GRAND AVE. 11FJC
ST. LOUIS MO
63106
US

IV. Provider business mailing address

3042 JAMIE CT
ARNOLD MO
63010-2573
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-289-7612
Mailing address:
  • Phone: 636-282-0951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number113743
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: