Provider Demographics
NPI:1609827708
Name:ADAMS, AMY (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ADAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 LINCOLN BLVD
Mailing Address - Street 2:DEPT : ER
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6306
Mailing Address - Country:US
Mailing Address - Phone:310-430-6586
Mailing Address - Fax:
Practice Address - Street 1:1328 TWENTY SECOND STREET
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-582-7089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2024-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13756207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13756Medicaid
P43097Medicare UPIN
CAPA13756Medicaid