Provider Demographics
NPI:1114195526
Name:AGENA, AMY L (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:AGENA
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 1:3540 VILLAGE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4706
Mailing Address - Country:US
Mailing Address - Phone:402-483-3885
Mailing Address - Fax:402-483-3886
Practice Address - Street 1:3540 VILLAGE DR STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4706
Practice Address - Country:US
Practice Address - Phone:402-483-3885
Practice Address - Fax:402-483-3886
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1364363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1364OtherLICENSE