NPI | 1003166984 |
---|---|
Former Name | AMANDA PHOENIX |
Entity Type | Individual |
Gender | Female |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2025008599) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085004469) |
Enumeration Date | 2012-09-18 |
Last Update Date | 2025-04-10 |