Basic Information
| Provider Information | |||||||||
| NPI: | 1659764595 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN J. PERSHING VAMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864151 | ||||||||
| FaxNumber: | 5737784190 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639013318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736864151 | ||||||||
| FaxNumber: | 5737784190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2015 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | BRADFORD | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | FAMILY NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 5737760905 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 2015006783 | MO | Y | Hospitals | General Acute Care Hospital | Rural |
No ID Information.