Healthcare Provider Details

I. General information

NPI: 1083147102
Provider Name (Legal Business Name): AMY COGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 N MERIDIAN ST STE 105
CARMEL IN
46290-1028
US

IV. Provider business mailing address

12251 S 80TH AVE STE 1520
PALOS HEIGHTS IL
60463-1290
US

V. Phone/Fax

Practice location:
  • Phone: 317-583-7800
  • Fax:
Mailing address:
  • Phone: 708-923-4200
  • Fax: 708-923-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10004787A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008955
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117662
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005054RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: