Basic Information
| Provider Information | |||||||||
| NPI: | 1972938249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODS | ||||||||
| FirstName: | TESSA | ||||||||
| MiddleName: | NORENE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658089007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775292 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2013 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 2017004407 | MO | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | BC5738387-0337 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0127X | 2017004407 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200043476 | 05 | MO | MEDICAID | 1972938249 | 05 | MO | MEDICAID |