Provider Demographics
NPI:1275837551
Name:MOLDENHAUER, MICHAEL J (NP-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MOLDENHAUER
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 OLD SAINT MARYS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1837
Mailing Address - Country:US
Mailing Address - Phone:573-547-3232
Mailing Address - Fax:573-547-3231
Practice Address - Street 1:624 OLD SAINT MARYS RD
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1837
Practice Address - Country:US
Practice Address - Phone:573-547-3232
Practice Address - Fax:573-547-3231
Is Sole Proprietor?:No
Enumeration Date:2010-12-31
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010040721363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily