Provider Demographics
NPI:1386744811
Name:DORRIS, JERRY W (FNP-C)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:DORRIS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 W DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MO
Mailing Address - Zip Code:65622-8669
Mailing Address - Country:US
Mailing Address - Phone:417-345-6101
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:118 W DALLAS ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-8669
Practice Address - Country:US
Practice Address - Phone:417-345-6101
Practice Address - Fax:417-829-4316
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO148324363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO421151309Medicaid
MO132680691Medicare PIN
Q77666Medicare UPIN
MO421151309Medicaid