Provider Demographics
NPI:1902079189
Name:WILLIAMS, AMANDA DAWN (DO)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:DAWN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N 36TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2954
Mailing Address - Country:US
Mailing Address - Phone:816-396-6026
Mailing Address - Fax:816-398-6896
Practice Address - Street 1:805 N 36TH ST STE B
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2954
Practice Address - Country:US
Practice Address - Phone:816-396-6026
Practice Address - Fax:816-398-6896
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007016867208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200642020AMedicaid
MO1902079189Medicaid
MO701000071Medicare PIN