Basic Information
Provider Information | |||||||||
NPI: | 1033323100 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WORKMAN | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 305 N 5TH ST | ||||||||
Address2: |   | ||||||||
City: | IRONTON | ||||||||
State: | OH | ||||||||
PostalCode: | 456381578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405323534 | ||||||||
FaxNumber: | 7405324859 | ||||||||
Practice Location | |||||||||
Address1: | 1408 CAMPBELL DR | ||||||||
Address2: | SUITE 201 | ||||||||
City: | IRONTON | ||||||||
State: | OH | ||||||||
PostalCode: | 456382301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405349202 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2007 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 22920 | WV | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 35.130305 | OH | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 7100099360 | 05 | KY |   | MEDICAID | 2933446 | 05 | OH |   | MEDICAID | 3810010436 | 05 | WV |   | MEDICAID |