Provider Demographics
NPI:1366748873
Name:PLASTOW, MICHAEL ALAN (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:PLASTOW
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 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-820-2000
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-885-0823
Practice Address - Fax:417-890-4178
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011002474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid
MOPENDINGMedicaid