Provider Demographics
NPI:1518252725
Name:HUKRIEDE, JOHN MALCOLM (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MALCOLM
Last Name:HUKRIEDE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7311
Mailing Address - Country:US
Mailing Address - Phone:417-322-6622
Mailing Address - Fax:417-350-1935
Practice Address - Street 1:1505 E BRADFORD PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6566
Practice Address - Country:US
Practice Address - Phone:417-322-6622
Practice Address - Fax:417-350-1935
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-488363A00000X
MO2011013290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR300293795Medicaid
MO220054154Medicaid