Basic Information
| Provider Information | |||||||||
| NPI: | 1053400457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOLSOM | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 HOSPITALITY DR | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638019382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710200 | ||||||||
| FaxNumber: | 5734717559 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 HOSPITALITY DR | ||||||||
| Address2: | |||||||||
| City: | SIKESTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638019382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734710200 | ||||||||
| FaxNumber: | 5734717559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2000150362 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.