Provider Demographics
NPI:1639450794
Name:POGUE, AMANDA ROSE (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:POGUE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5327 ROBERT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-4063
Mailing Address - Country:US
Mailing Address - Phone:314-517-6879
Mailing Address - Fax:
Practice Address - Street 1:5327 ROBERT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-4063
Practice Address - Country:US
Practice Address - Phone:314-517-6879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011025741225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant