Basic Information
| Provider Information | |||||||||
| NPI: | 1396944294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DETAR | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | WYATT | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEARCE | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | WYATT | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655369210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3799 RIDGEDALE RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | RIDGEDALE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173341936 | ||||||||
| FaxNumber: | 4173343055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2008030163 | MO | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 2008030163 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 2008030163 | MO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1396944294 | 05 | MO | MEDICAID |