Basic Information
Provider Information | |||||||||
NPI: | 1285783845 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HURST | ||||||||
FirstName: | RACHEL | ||||||||
MiddleName: | LYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMALL | ||||||||
OtherFirstName: | RACHEL | ||||||||
OtherMiddleName: | LYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4046 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658084046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4172695712 | ||||||||
FaxNumber: | 4172697567 | ||||||||
Practice Location | |||||||||
Address1: | 3801 S NATIONAL AVE | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MO | ||||||||
PostalCode: | 658075210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4172697728 | ||||||||
FaxNumber: | 4172697729 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2007 | ||||||||
LastUpdateDate: | 10/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2007001661 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 0600288 | 01 | MO | UNITED HEALTH CARE | OTHER | 431560263 | 01 | MO | TRICARE WEST | OTHER | 217261 | 01 | MO | BLUE CROSS/BLUE SHIELD | OTHER | Q75949 | 01 | MO | USPS (W/C) | OTHER | 1076297 | 01 |   | NCCPA BOARD CERTIFICATION | OTHER | 2565515 | 01 | MO | COX HEALTH | OTHER | 502277007 | 05 | MO |   | MEDICAID | P00823594 | 01 |   | RAILROAD MEDICARE-SJC | OTHER | 0219383 | 01 | WA | DEBARTMENT OF LABOR WA | OTHER |