Provider Demographics
NPI:1215900048
Name:ELDER, AMANDA JEAN (PAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:ELDER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEAN
Other - Last Name:ROMINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25277
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66225-5277
Mailing Address - Country:US
Mailing Address - Phone:918-307-6920
Mailing Address - Fax:918-307-6951
Practice Address - Street 1:1705 E 19TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5405
Practice Address - Country:US
Practice Address - Phone:918-748-7585
Practice Address - Fax:918-403-6352
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00878501OtherMEDICARE RAILROAD
OK200067560AMedicaid
OKOK403861Medicare PIN
Q59318Medicare UPIN
OK200067560AMedicaid