Provider Demographics
NPI:1235653288
Name:ANDERSON, AMY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:113 WAITE AVENUE SOUTH #101
Mailing Address - Street 2:CENTRACARE CLINIC CONVENIENCE CARE WAITE PARK
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1348
Mailing Address - Country:US
Mailing Address - Phone:320-656-7127
Mailing Address - Fax:
Practice Address - Street 1:14600 SW MURRAY SCHOLLS DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9712
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN12437363A00000X
ORPA203713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant