Provider Demographics
NPI:1831167105
Name:DEAN, MICHAEL JASON (RN ANP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JASON
Last Name:DEAN
Suffix:
Gender:M
Credentials:RN ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 PRESIDENTS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-8475
Mailing Address - Country:US
Mailing Address - Phone:636-866-1293
Mailing Address - Fax:
Practice Address - Street 1:1400 PRESIDENTS LANDING DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-8475
Practice Address - Country:US
Practice Address - Phone:636-866-1293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-74934-022363L00000X
MO2000167996163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177840901Medicaid
KS200622300AMedicaid
KS068002060Medicare PIN
KS200622300AMedicaid
TX8G1704Medicare ID - Type Unspecified