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NPI Code Detail

MEDICARE: ESRY STUDENT HEALTH CENTER MISSOURI WESTERN STATE

MEDICARE: ESRY STUDENT HEALTH CENTER MISSOURI WESTERN STATE
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
1363LF0000XFamily Nurse Practitioner138383MO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11801099874OTHERMONP TYPE I NPI

General Provider Information

NPI Number : 1962859090
Entity Type Code : Organization
Provider Name (Legal Business Name) : ESRY STUDENT HEALTH CENTER MISSOURI WESTERN STATE
Provider Business Mailing Address
First Line : 4525 DOWNS DR
Second Line : BLUM UNION ROOM 203
City : SAINT JOSEPH
State : MO
Zip : 64507-2246
Country : US
Telephone Number : 816-271-4495
Fax Number : 816-271-4496
Provider Business Practice Location Address
First Line : 4525 DOWNS DR
Second Line : BLUM UNION ROOM 203
City : SAINT JOSEPH
State : MO
Zip : 64507-2246
Country : US
Telephone Number : 816-271-4495
Fax Number : 816-271-4496
Authorized Official
Title or Position : NURSE PRACTICTIONER
Name : ELIZABETH RODERICK
Credential : FNP
Telephone Number : 816-271-4495
Provider Enumeration Date : 05/18/2016
Last Update Date : 05/18/2016

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Directions to “ESRY STUDENT HEALTH CENTER MISSOURI WESTERN STATE ” Practice Location

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