Provider Demographics
NPI:1972696813
Name:DUSENBERRY, AMY LYNN (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:DUSENBERRY
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 1:332 SANTA FE DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5143
Mailing Address - Country:US
Mailing Address - Phone:760-943-6700
Mailing Address - Fax:760-632-4292
Practice Address - Street 1:332 SANTA FE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5143
Practice Address - Country:US
Practice Address - Phone:760-943-6700
Practice Address - Fax:760-632-4292
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17340363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093170Medicaid
CA03-0431018OtherTRI CARE
CAZZZ04918ZOtherBLUE SHIELD
CAGR0093170Medicaid