Basic Information
| Provider Information | |||||||||
| NPI: | 1194019968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTIAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | CLAY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648033810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173474662 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3302 MCINTOSH CIR STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648043639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173477272 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | 2015006389 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 2015006389 | MO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200022972 | 05 | MO | MEDICAID |