Provider Demographics
NPI:1013959006
Name:HERTWECK-WARNER, AMY L (DO)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:HERTWECK-WARNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1368
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-8368
Mailing Address - Country:US
Mailing Address - Phone:405-745-9600
Mailing Address - Fax:405-745-9602
Practice Address - Street 1:1905 W 32ND ST
Practice Address - Street 2:SUITE 103
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1529
Practice Address - Country:US
Practice Address - Phone:417-659-6967
Practice Address - Fax:405-745-9602
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOMA2082142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO245828405Medicaid
P00760838OtherRAILROAD MEDICARE
AR179498003Medicaid
MO245828405Medicaid
AR179498003Medicaid
MO132300101Medicare PIN