Basic Information
| Provider Information | |||||||||
| NPI: | 1760552285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENNEY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | GORDON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 69 NE 100 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608858858 | ||||||||
| FaxNumber: | 6608858496 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 NORTH SECOND ST | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647351192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608907103 | ||||||||
| FaxNumber: | 6608858496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 073437 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 912688322 | 05 | MO | MEDICAID |