Provider Demographics
NPI:1598439713
Name:BLACK, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11921 W STATE HIGHWAY YY
Mailing Address - Street 2:
Mailing Address - City:EAGLEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64442-9193
Mailing Address - Country:US
Mailing Address - Phone:660-373-2134
Mailing Address - Fax:
Practice Address - Street 1:302 NE 14TH ST
Practice Address - Street 2:
Practice Address - City:LEON
Practice Address - State:IA
Practice Address - Zip Code:50144-1206
Practice Address - Country:US
Practice Address - Phone:641-446-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA164712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily