Provider Demographics
NPI:1073515714
Name:EMMONS, MARCY A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARCY
Middle Name:A
Last Name:EMMONS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:A
Other - Last Name:SCHULTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-5583
Mailing Address - Fax:573-331-5079
Practice Address - Street 1:2130 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2907
Practice Address - Country:US
Practice Address - Phone:573-243-8408
Practice Address - Fax:573-243-0445
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002359363A00000X
MO2022040627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077854Medicaid
422140Medicare ID - Type Unspecified
IL036077854Medicaid