# NORTHWEST MISSOURI STATE UNIVERSITY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Northwest Missouri State
- **Organization subpart:** No

## Provider details

- **NPI number:** 1225310204
- **Authorized official:** MATTHEW CANNELLA LAT (HEAD ATHLETIC TRAINER)
- **Authorized official phone:** (660) 562-1313

## Contact information

- **Practice address:** 800 UNIVERSITY DRIVE, MARYVILLE, MO 64468
- **Practice address phone:** (660) 562-1313
- **Mailing address:** 800 UNIVERSITY DRIVE, MARYVILLE, MO 64468
- **Mailing address phone:** (660) 562-1313

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 2255A2300X | Athletic Trainer | — | NULL | — |
| 2255A2300X | Athletic Trainer | — | — | — |

## Other

- **Enumeration date:** 09/15/2011
- **Last updated:** 02/21/2022