Provider Demographics
NPI:1710192075
Name:PALUMBO, AMANDA D (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:D
Last Name:PALUMBO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22722 STATE HIGHWAY 74
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-6953
Mailing Address - Country:US
Mailing Address - Phone:405-802-3905
Mailing Address - Fax:
Practice Address - Street 1:700 S TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2502
Practice Address - Country:US
Practice Address - Phone:405-793-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicare UPIN