Provider Demographics
NPI:1629030598
Name:SPRAGUE, AMY M (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:M
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-1164
Mailing Address - Fax:503-494-5502
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-1164
Practice Address - Fax:503-494-5502
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD195005207R00000X, 207RN0300X, 208M00000X
GA035145207RN0300X
SC15949207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC15949OtherSC LICENSE #
SCG35145Medicaid
GA000506701IMedicaid
GA035145OtherGA LICENSE #
GA035145OtherGA LICENSE #
GA39BDBRWMedicare ID - Type UnspecifiedGA MEDICARE
GA035145OtherGA LICENSE #
GA000506701IMedicaid