Provider Demographics
NPI:1265874366
Name:KOMLANVI, AMI (PA-C)
Entity type:Individual
Prefix:
First Name:AMI
Middle Name:
Last Name:KOMLANVI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18580 JOPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4218
Mailing Address - Country:US
Mailing Address - Phone:952-892-9500
Mailing Address - Fax:
Practice Address - Street 1:18580 JOPLIN AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-4218
Practice Address - Country:US
Practice Address - Phone:952-892-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1265874366Medicaid
MN1265874366Medicaid