Provider Demographics
NPI:1699334649
Name:PIATT, JOHN ROBERT (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:PIATT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1100
Mailing Address - Country:US
Mailing Address - Phone:417-257-6789
Mailing Address - Fax:417-257-5828
Practice Address - Street 1:1100 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775
Practice Address - Country:US
Practice Address - Phone:417-257-6789
Practice Address - Fax:417-257-5828
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019029281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019029281OtherSTATE LICENSE