Provider Demographics
NPI:1568493823
Name:ETSELL, AMY E (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:ETSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 HIGHWAY 161
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:MO
Mailing Address - Zip Code:63334-2431
Mailing Address - Country:US
Mailing Address - Phone:733-243-3335
Mailing Address - Fax:573-324-3334
Practice Address - Street 1:905 HIGHWAY 161
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-2431
Practice Address - Country:US
Practice Address - Phone:573-324-3333
Practice Address - Fax:573-324-3334
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016018119363A00000X
TN310171363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCM1497OtherRAILROAD MEDICARE