MEDICARE: MISSOURI GATEWAY HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1073052114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI GATEWAY HEALTH, LLC

Provider Business Mailing Address
First Line	:	10900 NUCKOLS RD
Second Line	:	SUITE 110
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-9276
Country	:	US
Telephone Number	:	804-396-6412
Fax Number	:	804-482-2756

Provider Business Practice Location Address
First Line	:	10900 NUCKOLS RD
Second Line	:	STE 110
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-9276
Country	:	US
Telephone Number	:	804-396-6412
Fax Number	:	804-482-2756

Authorized Official
Title or Position	:	COO
Name	:	KENNETH BRATTON
Credential	:
Telephone Number	:	804-396-6412

Provider Enumeration Date	:	02/22/2017
Last Update Date	:	02/22/2017

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