Provider Demographics
NPI:1720412851
Name:AMY, LAUREN A (PAC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:A
Last Name:AMY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:KS
Mailing Address - Zip Code:67865-0127
Mailing Address - Country:US
Mailing Address - Phone:620-885-4202
Mailing Address - Fax:620-885-4805
Practice Address - Street 1:222 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLOOM
Practice Address - State:KS
Practice Address - Zip Code:67865-8511
Practice Address - Country:US
Practice Address - Phone:620-885-4202
Practice Address - Fax:620-885-4805
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501625363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical