Basic Information
| Provider Information | |||||||||
| NPI: | 1134606858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULLEY | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | GENE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 708760 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840708760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013529500 | ||||||||
| FaxNumber: | 8013527976 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 OAK GROVE RD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639011573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737762000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209017813 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 2018004234 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.