Provider Demographics
NPI:1952647273
Name:FIEDLER, AMY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FIEDLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:KOEHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2413 EMILY LN
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-8743
Mailing Address - Country:US
Mailing Address - Phone:815-721-0107
Mailing Address - Fax:
Practice Address - Street 1:5666 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2425
Practice Address - Country:US
Practice Address - Phone:815-395-5462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004533363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant