Provider Demographics
NPI:1649431255
Name:DOHERTY, AMY LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LYNN
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 20859
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-0859
Mailing Address - Country:US
Mailing Address - Phone:414-914-9430
Mailing Address - Fax:414-914-9444
Practice Address - Street 1:6150 W LAYTON AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4608
Practice Address - Country:US
Practice Address - Phone:414-914-9430
Practice Address - Fax:414-914-9444
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2286-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant