Basic Information
| Provider Information | |||||||||
| NPI: | 1437564408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEMMONS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | CATHLEEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 TULANE AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701194100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048212601 | ||||||||
| FaxNumber: | 5042673014 | ||||||||
| Practice Location | |||||||||
| Address1: | 3308 TULANE AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701197100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5042072273 | ||||||||
| FaxNumber: | 5042936912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 301776 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2449621 | 05 | LA | MEDICAID |