Provider Demographics
NPI:1073319232
Name:MERISOTES, CYSCO ALLEN
Entity type:Individual
Prefix:
First Name:CYSCO
Middle Name:ALLEN
Last Name:MERISOTES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:FAIR GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65648-8433
Mailing Address - Country:US
Mailing Address - Phone:417-849-1172
Mailing Address - Fax:
Practice Address - Street 1:2115 S FREMONT AVE STE 5000
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2230
Practice Address - Country:US
Practice Address - Phone:417-820-3912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025000589363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical