Provider Demographics
NPI:1801099718
Name:CHISHOLM, AMY LENEE (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LENEE
Last Name:CHISHOLM
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 1:1105 CENTRAL EXPY N STE 2100
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6120
Mailing Address - Country:US
Mailing Address - Phone:972-747-6401
Mailing Address - Fax:
Practice Address - Street 1:1105 CENTRAL EXPY N STE 2100
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6120
Practice Address - Country:US
Practice Address - Phone:972-747-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB143188Medicare PIN
TXTXB143187Medicare PIN
TXTXB143186Medicare PIN