Provider Demographics
NPI:1184874919
Name:WAUGH, AMANDA DAWN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:WAUGH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DAWN
Other - Last Name:HORNBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAN ASSISTANT
Mailing Address - Street 1:1400 E BOULDER ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5533
Mailing Address - Country:US
Mailing Address - Phone:719-364-6487
Mailing Address - Fax:719-364-6488
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:SUITE 600
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-364-6487
Practice Address - Fax:719-364-6488
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2665363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29855039Medicaid