Basic Information
| Provider Information | |||||||||
| NPI: | 1841464732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PIPKIN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | SAN U | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAN U | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 AUSTIN DR | ||||||||
| Address2: | |||||||||
| City: | DEMOREST | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305354513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067548066 | ||||||||
| FaxNumber: | 7067548086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1715 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 001715 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 602701555D | 05 | GA | MEDICAID | 610308 | 01 | GA | WELLCARE | OTHER | 602701555C | 05 | GA | MEDICAID | 602701555B | 05 | GA | MEDICAID | 01457792 | 01 | GA | AMERIGROUP | OTHER | 602701555E | 05 | GA | MEDICAID |