Provider Demographics
NPI:1255303681
Name:MAXWELL, TAMULA K (PA-C)
Entity Type:Individual
Prefix:
First Name:TAMULA
Middle Name:K
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26180 E STATE HIGHWAY MM
Mailing Address - Street 2:
Mailing Address - City:GILMAN CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64642-8139
Mailing Address - Country:US
Mailing Address - Phone:660-425-2365
Mailing Address - Fax:
Practice Address - Street 1:3202 MILLER ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-2713
Practice Address - Country:US
Practice Address - Phone:660-425-3154
Practice Address - Fax:660-425-6663
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003006425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2003006425OtherLICENSE NUMBER