Individual
MATTHEW DALE TIESKOETTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
APRN
Contact information
Practice address
12349 DE PAUL DR STE 100, BRIDGETON, MO 63044-2512
(314) 291-7900
Mailing address
PO BOX 955534, SAINT LOUIS, MO 63195-5534
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
2020003584
MO
Other
Enumeration date
06/25/2020
Last updated
10/17/2022
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