Provider Demographics
NPI:1790057016
Name:CASE, AMBER NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:NICOLE
Last Name:CASE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:N
Other - Last Name:COZBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2716 W REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-3901
Mailing Address - Country:US
Mailing Address - Phone:417-881-8812
Mailing Address - Fax:
Practice Address - Street 1:2716 W REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-3901
Practice Address - Country:US
Practice Address - Phone:417-881-8812
Practice Address - Fax:417-881-1618
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012002692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MOP01036359OtherRR MCR
MO431560263OtherTRICARE