Basic Information
| Provider Information | |||||||||
| NPI: | 1174838759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NATHALANG-PINON | ||||||||
| FirstName: | ANI | ||||||||
| MiddleName: | GUNYAPORN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DURHAM | ||||||||
| OtherFirstName: | ANI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1125 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651015227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736325700 | ||||||||
| FaxNumber: | 5736325715 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651015227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736325700 | ||||||||
| FaxNumber: | 5736325715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2010 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2010020278 | MO | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.