Healthcare Provider Details

I. General information

NPI: 1992716674
Provider Name (Legal Business Name): AMY LOUISE MCKINLAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 W CHUBBUCK RD
CHUBBUCK ID
83202-2314
US

IV. Provider business mailing address

255 S 20TH AVE
POCATELLO ID
83201-3337
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-7546
  • Fax: 208-237-9643
Mailing address:
  • Phone: 208-317-2513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-563
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: