Provider Demographics
NPI:1316059793
Name:WARD, AMANDA HOWINGTON (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:HOWINGTON
Last Name:WARD
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1605 WHITESVILLE ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-5903
Mailing Address - Country:US
Mailing Address - Phone:706-882-5119
Mailing Address - Fax:706-882-0270
Practice Address - Street 1:1605 WHITESVILLE ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5903
Practice Address - Country:US
Practice Address - Phone:706-882-5119
Practice Address - Fax:706-882-0270
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA521729Medicare UPIN