Provider Demographics
NPI:1295787760
Name:IMPERATO, PAUL JOSEPH (CRNA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:JOSEPH
Last Name:IMPERATO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 HIGHWAY 54 PO BOX 840
Mailing Address - Street 2:SUITE F
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065
Mailing Address - Country:US
Mailing Address - Phone:573-302-1661
Mailing Address - Fax:573-302-1719
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN2000162294367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO917196404Medicaid
MO852630247Medicare ID - Type Unspecified
MO825630246Medicare ID - Type Unspecified