Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 2017017909 | MO |
N | 208800000X | Urologist | 228628-1 | NY |
NPI | 1003903550 |
---|---|
Provider Name | Jennifer A Malossi |
First Address | Springfield, MO 65808-9007 |
Second Address | Springfield, MO 65807-5155 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2006 |
Last Update Date | 27/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003903550 | (05) | MO |
200044423 | (05) | MO |
H89304 | (02) | NY |