Basic Information
Provider Information | |||||||||
NPI: | 1770891608 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POPE | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OMAHEN | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A.-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 600 EAST BLVD | ||||||||
Address2: |   | ||||||||
City: | ELKHART | ||||||||
State: | IN | ||||||||
PostalCode: | 465142483 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5745233160 | ||||||||
FaxNumber: | 5745233221 | ||||||||
Practice Location | |||||||||
Address1: | 600 EAST BLVD | ||||||||
Address2: |   | ||||||||
City: | ELKHART | ||||||||
State: | IN | ||||||||
PostalCode: | 465142483 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5745233160 | ||||||||
FaxNumber: | 5745233221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2010 | ||||||||
LastUpdateDate: | 05/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-003846 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.