Provider Demographics
NPI:1619209186
Name:MILLEMON, AMANDA R (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:MILLEMON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 PACIFIC ST
Mailing Address - Street 2:STE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-1044
Mailing Address - Country:US
Mailing Address - Phone:402-504-3707
Mailing Address - Fax:402-504-3714
Practice Address - Street 1:3830 N 167TH CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-8067
Practice Address - Country:US
Practice Address - Phone:402-965-4000
Practice Address - Fax:402-965-4001
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE1493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1493OtherNE LICENSE
NE1493OtherNE LICENSE