Provider Demographics
NPI:1346316692
Name:DYVIG, AMANDA J (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:DYVIG
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 1:1575 SE OLSON DR
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8260
Mailing Address - Country:US
Mailing Address - Phone:515-987-8991
Mailing Address - Fax:
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:STE 417
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2350
Practice Address - Country:US
Practice Address - Phone:515-263-5684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP78882Medicare UPIN
IAI8291Medicare ID - Type UnspecifiedIMMC
I8290Medicare ID - Type UnspecifiedILH