Provider Demographics
NPI:1417402058
Name:LANHAM, AMANDA JO (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:LANHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:SPRINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10000 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4321
Mailing Address - Country:US
Mailing Address - Phone:414-454-8000
Mailing Address - Fax:414-805-3808
Practice Address - Street 1:10000 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4321
Practice Address - Country:US
Practice Address - Phone:414-454-8000
Practice Address - Fax:414-805-3808
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4686363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417402058Medicaid