Healthcare Provider Details

I. General information

NPI: 1679512305
Provider Name (Legal Business Name): CHARLES JOSEPH AMY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 UINTA DR
GREEN RIVER WY
82935-5046
US

IV. Provider business mailing address

PO BOX 219
GREEN RIVER WY
82935-0219
US

V. Phone/Fax

Practice location:
  • Phone: 307-872-4500
  • Fax: 307-872-4595
Mailing address:
  • Phone: 307-872-4500
  • Fax: 307-872-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number72
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: