Provider Demographics
NPI:1174284467
Name:JUNUZOVIC, AIDA
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:JUNUZOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 PARK LAWN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-2462
Mailing Address - Country:US
Mailing Address - Phone:314-560-1507
Mailing Address - Fax:
Practice Address - Street 1:12266 DEPAUL DR SUITE 100
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-738-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-07
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program