Provider Demographics
NPI:1992956353
Name:AMIS, DOUGLAS EDWARD (PA)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:AMIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4411
Mailing Address - Country:US
Mailing Address - Phone:603-569-7500
Mailing Address - Fax:
Practice Address - Street 1:240 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4411
Practice Address - Country:US
Practice Address - Phone:603-569-7500
Practice Address - Fax:603-515-2031
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2211363A00000X
CO2684363A00000X
NH1031363A00000X
GA10381363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO021137OtherKAISER COMMERCIAL NUMBER
CO66500753Medicaid
CO021137OtherKAISER COMMERCIAL NUMBER
AK021310Medicare Oscar/Certification
AKTEZ042Medicare PIN