Provider Demographics
NPI:1316163595
Name:SIMPSON, AMANDA JADE (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JADE
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:JADE
Other - Last Name:GARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4340 CLYO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7000
Mailing Address - Country:US
Mailing Address - Phone:937-534-7330
Mailing Address - Fax:937-395-3682
Practice Address - Street 1:4340 CLYO RD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-7000
Practice Address - Country:US
Practice Address - Phone:937-534-7330
Practice Address - Fax:937-395-3682
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002327RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0393422Medicaid