Provider Demographics
NPI:1841464732
Name:PIPKIN, AMANDA SAN U (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SAN U
Last Name:PIPKIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DAWN
Other - Last Name:SAN U
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:247 ADAMS DRIVE
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-839-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1715363AM0700X
GA5323363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA602701555BMedicaid
GA602701555CMedicaid
GA602701555DMedicaid
GA602701555EMedicaid
GA01457792OtherAMERIGROUP
GA610308OtherWELLCARE
GA602701555BMedicaid