Emily L Wickersham, DO

Primary specialty

Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X

License

2024028249 Issued in MO

Practice address

1500 N Oakland Ave
Bolivar, MO 65613-3099

Phone

(417) 326-6000

NPI assigned

Feb 29, 2016

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other names 1

• Emily Louise Mientus Other name

Medicare fee-for-service enrollment

Enrolled in MO

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Pathology

Education

Other, 2020

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Citizens Memorial Hospital DistrictGroup PAC ID 2769574433, 50 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Citizens Memorial Hospital Hospital, Bolivar, MO, CCN 260195

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Citizens Memorial Hospital District

  • Emergency Medicine Physician
  • Bolivar, MO
  • NPI 1558548818
  Medicare reassignment Care Compare group NPD
• Citizens Memorial Hospital District

  • Community/Retail Pharmacy
  • Buffalo, MO
  • NPI 1427480995
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Citizens Memorial Hospital District

  • General Acute Care Hospital
  • Bolivar, MO
  • NPI 1003981549
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1456704000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1786665600000",
    "number": "1093175358",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19135 PAWNEE CT",
            "city": "SAINT JOSEPH",
            "state": "MO",
            "postal_code": "645058901",
            "telephone_number": "309-258-5813"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1500 N OAKLAND AVE",
            "city": "BOLIVAR",
            "state": "MO",
            "postal_code": "656133099",
            "telephone_number": "417-326-6000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1 Kish Hospital Dr",
            "address_purpose": "LOCATION",
            "city": "Dekalb",
            "state": "IL",
            "postal_code": "601159602",
            "country_code": "US",
            "telephone_number": "815-756-1521",
            "fax_number": "815-766-9647",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WICKERSHAM",
        "first_name": "EMILY",
        "middle_name": "L",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-02-29",
        "last_updated": "2026-08-14",
        "certification_date": "2026-08-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "MO",
            "license": "2024028249",
            "primary": true
        },
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "IL",
            "license": "036.177695",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "EMILY",
            "last_name": "MIENTUS",
            "middle_name": "LOUISE",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Sno White-Benson, RPH, PHARM D.
• Kelley White
• Whole and Balanced Therapy Services, LLC
• Caitlin M Williams, ATC
• Danielle Elise Williams, OTR
• Christopher D Willis, DO
• Charles Jay Wilson, MA, LPC
• Kayla Ruth Windes

• Anatomic Pathology & Clinical Pathology Physician in Bolivar, MO
• Providers in Bolivar, MO by specialty
• Anatomic Pathology & Clinical Pathology Physician in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.