Provider Demographics
NPI:1083065395
Name:UNDERWOOD, AMELIA I (RD, CDE, PA-C)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:UNDERWOOD
Suffix:I
Gender:F
Credentials:RD, CDE, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 MCCRAY ST STE 231
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-2224
Mailing Address - Country:US
Mailing Address - Phone:831-444-2289
Mailing Address - Fax:
Practice Address - Street 1:591 MCCRAY ST STE 231
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-2224
Practice Address - Country:US
Practice Address - Phone:831-444-2289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 133V00000X
CA53421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53421OtherPHYSICIAN ASSISTANT