Healthcare Provider Details

I. General information

NPI: 1417402058
Provider Name (Legal Business Name): AMANDA JO LANHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA JO SPRINGER

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 HOOVER ST
NEW HOLSTEIN WI
53061-1636
US

IV. Provider business mailing address

PO BOX 74008272
CHICAGO IL
60674-8272
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 872-231-3162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4686
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: