Basic Information
| Provider Information | |||||||||
| NPI: | 1427005792 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICIRO | ||||||||
| FirstName: | SONYA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | F.N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOODSMALL | ||||||||
| OtherFirstName: | SONYA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | F.N.P. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 225 PHYSICIANS PARK | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737275500 | ||||||||
| FaxNumber: | 5737275599 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 PHYSICIANS PARK | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737275500 | ||||||||
| FaxNumber: | 5737275599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 01/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 093231 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 428892707 | 05 | MO | MEDICAID |