Provider Demographics
NPI:1477792869
Name:CRIM, AMANDA M (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:CRIM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:FURTADO, HODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 504274
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4274
Mailing Address - Country:US
Mailing Address - Phone:855-420-7900
Mailing Address - Fax:
Practice Address - Street 1:94 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-1610
Practice Address - Country:US
Practice Address - Phone:417-847-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009001274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602630075OtherMEDICARE
MO1477792869Medicaid
P00689756OtherRAILROAD MEDICARE
431560263OtherTRICARE WEST
MO1477792869Medicaid