Provider Demographics
NPI:1467952606
Name:MOOTY, JAMES JEREMIAH (FNP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JEREMIAH
Last Name:MOOTY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-472-7406
Mailing Address - Fax:
Practice Address - Street 1:1008 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5044
Practice Address - Country:US
Practice Address - Phone:573-472-6001
Practice Address - Fax:573-472-6006
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018003400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily