Provider Demographics
NPI:1962859090
Name:ESRY STUDENT HEALTH CENTER MISSOURI WESTERN STATE
Entity Type:Organization
Organization Name:ESRY STUDENT HEALTH CENTER MISSOURI WESTERN STATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTICTIONER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RODERICK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:816-271-4495
Mailing Address - Street 1:4525 DOWNS DR
Mailing Address - Street 2:BLUM UNION ROOM 203
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2246
Mailing Address - Country:US
Mailing Address - Phone:816-271-4495
Mailing Address - Fax:816-271-4496
Practice Address - Street 1:4525 DOWNS DR
Practice Address - Street 2:BLUM UNION ROOM 203
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2246
Practice Address - Country:US
Practice Address - Phone:816-271-4495
Practice Address - Fax:816-271-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138383363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1801099874OtherNP TYPE I NPI