Provider Demographics
NPI:1104047141
Name:UNIVERSITY OF MISSOURI ST. LOUIS
Entity type:Organization
Organization Name:UNIVERSITY OF MISSOURI ST. LOUIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASST. VICE PROVOST STUDENT AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DSN, APRN, CS, FNP
Authorized Official - Phone:314-516-5671
Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:MILLENIUM STUDENT CENTER 131
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:314-516-5671
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY BLVD
Practice Address - Street 2:MILLENIUM STUDENT CENTER 131
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4400
Practice Address - Country:US
Practice Address - Phone:314-516-5671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO134958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty