Provider Demographics
NPI:1225364748
Name:FALLOS, AMANDA SHER (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHER
Last Name:FALLOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:
Practice Address - Street 1:3939 CENTRAL PIKE
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-3499
Practice Address - Country:US
Practice Address - Phone:615-883-2331
Practice Address - Fax:615-391-1785
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1758363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN621798471OtherGROUP TAX ID
TN1526983Medicaid
12328183OtherCAQH
TN1526983Medicaid