Provider Demographics
NPI:1760552285
Name:MCKENNEY, THOMAS GORDON
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GORDON
Last Name:MCKENNEY
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 1:69 NE 100
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735
Mailing Address - Country:US
Mailing Address - Phone:660-885-8858
Mailing Address - Fax:660-885-8496
Practice Address - Street 1:1600 NORTH SECOND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:660-890-7103
Practice Address - Fax:660-885-8496
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO073437367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO912688322Medicaid
MO912688322Medicaid