Provider Demographics
NPI:1457418857
Name:REDFISH, AMIEL NARCELLE (PA)
Entity Type:Individual
Prefix:
First Name:AMIEL
Middle Name:NARCELLE
Last Name:REDFISH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 291
Mailing Address - Street 2:104 W. BIRCH
Mailing Address - City:ARLINGTON
Mailing Address - State:SD
Mailing Address - Zip Code:57212-0291
Mailing Address - Country:US
Mailing Address - Phone:605-983-3283
Mailing Address - Fax:605-983-5112
Practice Address - Street 1:104 W BIRCH
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:SD
Practice Address - Zip Code:57212-0291
Practice Address - Country:US
Practice Address - Phone:605-983-3283
Practice Address - Fax:605-983-5112
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD0173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5300830Medicaid
SDR02492Medicare UPIN
SD5300830Medicaid