MEDICARE: AMANDA ROSE POGUE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2011025741	MO

General Provider Information

NPI Number	:	1639450794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ROSE POGUE PTA

Provider Business Mailing Address
First Line	:	5327 ROBERT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-4063
Country	:	US
Telephone Number	:	314-517-6879
Fax Number	:

Provider Business Practice Location Address
First Line	:	5327 ROBERT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-4063
Country	:	US
Telephone Number	:	314-517-6879
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2011
Last Update Date	:	09/02/2011

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