Provider Demographics
NPI:1487626826
Name:RISLEY, AMY B (PA)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:B
Last Name:RISLEY
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Mailing Address - Street 1:8100 S WALKER AVE
Mailing Address - Street 2:BLDG A
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9404
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-632-2323
Practice Address - Fax:405-631-9315
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1111363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200067440AMedicaid
OK970025354OtherRAILROAD MEDICARE
OKPA001111Medicare PIN
OK970025354OtherRAILROAD MEDICARE