Basic Information
| Provider Information | |||||||||
| NPI: | 1962020560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUGATE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | AGPCNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15730 N STATE HIGHWAY 130 | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624483273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176635414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 PALM AVE | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619386031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883656271 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2020 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 209021558 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.