Provider Demographics
NPI:1194426767
Name:HARPER, MONDRAKUS
Entity type:Individual
Prefix:
First Name:MONDRAKUS
Middle Name:
Last Name:HARPER
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 1:12565 EVENING SHADE DR
Mailing Address - Street 2:
Mailing Address - City:BLACK JACK
Mailing Address - State:MO
Mailing Address - Zip Code:63033-8513
Mailing Address - Country:US
Mailing Address - Phone:314-583-1477
Mailing Address - Fax:314-216-3926
Practice Address - Street 1:12565 EVENING SHADE DR
Practice Address - Street 2:
Practice Address - City:BLACK JACK
Practice Address - State:MO
Practice Address - Zip Code:63033-8513
Practice Address - Country:US
Practice Address - Phone:314-583-1477
Practice Address - Fax:314-216-3926
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYB6P44F8Q3246RP1900X
MO134849376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No376K00000XNursing Service Related ProvidersNurse's Aide