Provider Demographics
NPI:1740399880
Name:SHILS, AMANDA C (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:SHILS
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 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3832
Mailing Address - Country:US
Mailing Address - Phone:217-464-1470
Mailing Address - Fax:217-464-5163
Practice Address - Street 1:4965 E LOST BRIDGE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5139
Practice Address - Country:US
Practice Address - Phone:217-864-5531
Practice Address - Fax:217-864-2449
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001947363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ11504Medicare UPIN
ILK05065Medicare PIN