Provider Demographics
NPI:1043260383
Name:DANIELS, AMIE RENEE (PA)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:RENEE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 TRADERS PASS
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2206
Mailing Address - Country:US
Mailing Address - Phone:478-953-6734
Mailing Address - Fax:478-953-6734
Practice Address - Street 1:2054 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3634
Practice Address - Country:US
Practice Address - Phone:478-918-0770
Practice Address - Fax:478-918-0771
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCHGXMedicare PIN
GAQ62170Medicare UPIN