Provider Demographics
NPI:1730222845
Name:WELCH, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WELCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35629
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-0629
Mailing Address - Country:US
Mailing Address - Phone:214-424-2213
Mailing Address - Fax:214-231-2170
Practice Address - Street 1:1850 LAKEPOINTE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-6442
Practice Address - Country:US
Practice Address - Phone:972-316-0262
Practice Address - Fax:972-316-8762
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2690Medicare ID - Type UnspecifiedPROVIDER NUMBER
TX00080TMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER