Basic Information
| Provider Information | |||||||||
| NPI: | 1477792869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRIM | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FURTADO, HODGE | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | M. | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 504274 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631504274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554207900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 94 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CASSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656251610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178476000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2009001274 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 602630075 | 01 | MO | MEDICARE | OTHER | 1477792869 | 05 | MO | MEDICAID | P00689756 | 01 | RAILROAD MEDICARE | OTHER | 431560263 | 01 | TRICARE WEST | OTHER |