Provider Demographics
NPI:1598090797
Name:VILAS, AMY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:VILAS
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 1:4071 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3801
Mailing Address - Country:US
Mailing Address - Phone:810-824-4222
Mailing Address - Fax:810-824-4220
Practice Address - Street 1:4071 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3801
Practice Address - Country:US
Practice Address - Phone:810-824-4222
Practice Address - Fax:810-824-4220
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005564363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598090797Medicaid
MI1598090797Medicaid