Provider Demographics
NPI:1396730479
Name:BEALS, AMIE DOUGHERTY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMIE
Middle Name:DOUGHERTY
Last Name:BEALS
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 1:2905 KILKENNY DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-7104
Mailing Address - Country:US
Mailing Address - Phone:937-418-8226
Mailing Address - Fax:
Practice Address - Street 1:140 W MAIN STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-1312
Practice Address - Country:US
Practice Address - Phone:937-398-1066
Practice Address - Fax:937-398-1076
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067790Medicaid
OH0067790Medicaid