Provider Demographics
NPI:1457399446
Name:MOEGGENBORG, AMEY LOU (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMEY
Middle Name:LOU
Last Name:MOEGGENBORG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AMEY
Other - Middle Name:LOU
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:611 COURT ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9390
Mailing Address - Country:US
Mailing Address - Phone:989-345-7000
Mailing Address - Fax:989-345-7479
Practice Address - Street 1:611 COURT ST
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9390
Practice Address - Country:US
Practice Address - Phone:989-345-7000
Practice Address - Fax:989-345-7479
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q28295Medicare UPIN
MIP02780001Medicare ID - Type Unspecified