Healthcare Provider Details

I. General information

NPI: 1891418448
Provider Name (Legal Business Name): AMANDA PENICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 HYLAND GREENS DR
BLOOMINGTON MN
55437-3934
US

IV. Provider business mailing address

8265 OBRIAN AVE NE
OTSEGO MN
55330-7413
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-2400
  • Fax: 952-993-2522
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14233
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: