Basic Information
| Provider Information | |||||||||
| NPI: | 1568085231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COMBS | ||||||||
| FirstName: | AUSTIN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 552 KOPP RD | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622981910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366988578 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9556 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631191313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143735740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2020 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2021034019 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.