Provider Demographics
NPI:1326001488
Name:CLYDE, AMY A (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:A
Last Name:CLYDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8053
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1000
Practice Address - Fax:617-421-6084
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1195363A00000X, 363AM0700X
MAPA1195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP1441Medicare ID - Type Unspecified
MAS97942Medicare UPIN