Provider Demographics
NPI:1215314745
Name:MCCOY, MISSIOURI D
Entity type:Individual
Prefix:
First Name:MISSIOURI
Middle Name:D
Last Name:MCCOY
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 1:2635 N 7TH ST
Mailing Address - Street 2:SMMG CVTS
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8209
Mailing Address - Country:US
Mailing Address - Phone:970-298-7662
Mailing Address - Fax:
Practice Address - Street 1:2643 PATTERSON RD
Practice Address - Street 2:STE 403
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1936
Practice Address - Country:US
Practice Address - Phone:970-298-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0991762-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily