Provider Demographics
NPI:1255305967
Name:SAILLIEZ, AMANDA S (PAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:SAILLIEZ
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CAPORALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:19 E SHAWNEE DR STE 2
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-7072
Practice Address - Country:US
Practice Address - Phone:618-684-2172
Practice Address - Fax:618-687-4480
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002568363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002568Medicaid
IL085002568Medicaid
IL214881083Medicare PIN
ILK23106Medicare Oscar/Certification
IL214881Medicare Oscar/Certification
ILQ57887Medicare UPIN