Provider Demographics
NPI:1407056682
Name:SCHULTZ, AMANDA LOUISE (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LOUISE
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LOUISE
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2115 STUART AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2269
Mailing Address - Country:US
Mailing Address - Phone:713-589-8082
Mailing Address - Fax:719-587-6354
Practice Address - Street 1:2115 STUART AVE
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2269
Practice Address - Country:US
Practice Address - Phone:719-589-8082
Practice Address - Fax:719-587-6354
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90027744Medicaid
CO90027744Medicaid