Healthcare Provider Details

I. General information

NPI: 1609597871
Provider Name (Legal Business Name): AMANDA K THATE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S KOKE MILL RD
SPRINGFIELD IL
62711-9252
US

IV. Provider business mailing address

PO BOX 9469
SPRINGFIELD IL
62791-9469
US

V. Phone/Fax

Practice location:
  • Phone: 217-547-9100
  • Fax:
Mailing address:
  • Phone: 217-547-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: