1841464732 NPI number — AMANDA SAN U PIPKIN PA

Table of content: AMANDA SAN U PIPKIN PA (NPI 1841464732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841464732 NPI number — AMANDA SAN U PIPKIN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIPKIN
Provider First Name:
AMANDA
Provider Middle Name:
SAN U
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAN U
Provider Other First Name:
AMANDA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841464732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742616
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-219-8420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
247 ADAMS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMOREST
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-839-4096
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1715 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 5323 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 602701555B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 602701555C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 602701555D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 602701555E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01457792 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 610308 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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