Provider Demographics
NPI:1649375098
Name:MORGAN, AMANDA V (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:V
Last Name:MORGAN
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 1:5717 OAKLAND DR
Mailing Address - Street 2:STE A
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1116
Mailing Address - Country:US
Mailing Address - Phone:269-323-4473
Mailing Address - Fax:269-324-0755
Practice Address - Street 1:551 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1595
Practice Address - Country:US
Practice Address - Phone:269-686-5800
Practice Address - Fax:269-686-5896
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004617363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q74553OtherUPIN
MI700H060020OtherBCBSM
P39040042Medicare PIN