Provider Demographics
NPI:1437564408
Name:CLEMMONS, AMANDA CATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CATHLEEN
Last Name:CLEMMONS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 TULANE AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-4100
Mailing Address - Country:US
Mailing Address - Phone:504-821-2601
Mailing Address - Fax:504-267-3014
Practice Address - Street 1:3308 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-7100
Practice Address - Country:US
Practice Address - Phone:504-207-2273
Practice Address - Fax:504-293-6912
Is Sole Proprietor?:No
Enumeration Date:2014-06-27
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA301776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2449621Medicaid