Provider Demographics
NPI:1871791699
Name:BLACK, AMY C (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1510 DIVISION ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1581
Practice Address - Country:US
Practice Address - Phone:503-650-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1031913363A00000X
ORPA163381363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500663461Medicaid
ORR172669Medicare PIN
ORR172668Medicare PIN
MOS48247Medicare UPIN
ORR172671Medicare PIN
ORR172667Medicare PIN
ORR172666Medicare PIN
OR500663461Medicaid
ORR172670Medicare PIN