Provider Demographics
NPI:1124560727
Name:ROBINSON, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROBINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W HACK ST
Mailing Address - Street 2:
Mailing Address - City:CULLOM
Mailing Address - State:IL
Mailing Address - Zip Code:60929-7133
Mailing Address - Country:US
Mailing Address - Phone:815-689-2126
Mailing Address - Fax:815-689-2131
Practice Address - Street 1:105 W HACK ST
Practice Address - Street 2:
Practice Address - City:CULLOM
Practice Address - State:IL
Practice Address - Zip Code:60929-7133
Practice Address - Country:US
Practice Address - Phone:815-689-2126
Practice Address - Fax:815-689-2131
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006059363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205941087OtherTIN