Provider Demographics
NPI:1386715399
Name:ALLEN, AMY MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:A
Other - Last Name:TIPTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3555 HARDEN STREET EXT
Mailing Address - Street 2:15 MEDICAL PARK
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6894
Mailing Address - Country:US
Mailing Address - Phone:803-545-5017
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:3209 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6930
Practice Address - Country:US
Practice Address - Phone:803-434-6113
Practice Address - Fax:803-434-4277
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103939363A00000X
SC2373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901642Medicaid
SC2288PAMedicaid
SCSC68512353Medicare PIN
NCQ58718Medicare UPIN