Provider Demographics
NPI:1336265487
Name:GENOVESE, JOSEPH A
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:GENOVESE
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:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:573-556-5757
Practice Address - Street 1:5950 UNIVERSITY AVE STE 105
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-7756
Practice Address - Country:US
Practice Address - Phone:515-875-9070
Practice Address - Fax:515-875-9071
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100229363LF0000X
IAA175174363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1336265487Medicaid
MO1336265487Medicaid