Basic Information
Provider Information | |||||||||
NPI: | 1396044780 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARNEY | ||||||||
FirstName: | MINDY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | YAEGER | ||||||||
OtherFirstName: | MINDY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1015 BOWLES AVE | ||||||||
Address2: |   | ||||||||
City: | FENTON | ||||||||
State: | MO | ||||||||
PostalCode: | 630262394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6364962000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1015 BOWLES AVE | ||||||||
Address2: |   | ||||||||
City: | FENTON | ||||||||
State: | MO | ||||||||
PostalCode: | 630262394 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6364962000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2011 | ||||||||
LastUpdateDate: | 01/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2012006738 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AM0700X |   |   | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.