Provider Demographics
NPI:1942929658
Name:AMOS, MICKEY (CNP)
Entity Type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:
Last Name:AMOS
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 WASHINGTON AVE SE STE 300
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2904
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:612-676-8992
Practice Address - Street 1:720 WASHINGTON AVE SE STE 300
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2904
Practice Address - Country:US
Practice Address - Phone:612-884-0649
Practice Address - Fax:612-676-8992
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9438363LG0600X, 363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology