Basic Information
| Provider Information | |||||||||
| NPI: | 1154792182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUSK | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARCUS | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 N LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472401327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174570586 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 720 N LINCOLN ST | ||||||||
| Address2: | |||||||||
| City: | GREENSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472401327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126634331 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2015 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10001920A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.