Provider Demographics
NPI:1972700193
Name:PRINCE, AMY MYRL
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MYRL
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1000 LINCOLN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3290
Mailing Address - Country:US
Mailing Address - Phone:970-542-4466
Mailing Address - Fax:970-867-4913
Practice Address - Street 1:1000 LINCOLN ST STE 101
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3290
Practice Address - Country:US
Practice Address - Phone:970-542-4466
Practice Address - Fax:970-867-4913
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0055211207PP0204X, 2080P0204X, 208000000X
MO2010019730208000000X
KS05-33934208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69050015Medicaid
CO413719YL2GMedicare PIN