Provider Demographics
NPI:1629321914
Name:WILLIAMS, AMANDA J (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:WILLIAMS
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 1:250 E SUPERIOR ST
Mailing Address - Street 2:SUITE 05-2235
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2914
Mailing Address - Country:US
Mailing Address - Phone:312-472-1234
Mailing Address - Fax:
Practice Address - Street 1:250 E SUPERIOR ST
Practice Address - Street 2:SUITE 05-2235
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2914
Practice Address - Country:US
Practice Address - Phone:312-472-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006509363A00000X
IL085005099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629321914Medicaid