| NPI | 1770196719 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DEBORAH HOUSEHOLDER Billing/Credentialing Manager 573-529-0072 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Enumeration Date | 2020-08-28 |
| Last Update Date | 2020-08-28 |