Provider Demographics
NPI:1366557209
Name:CHANG, AMIE C (PA)
Entity type:Individual
Prefix:MS
First Name:AMIE
Middle Name:C
Last Name:CHANG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11525 OLDE CABIN RD
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7146
Mailing Address - Country:US
Mailing Address - Phone:314-997-0554
Mailing Address - Fax:314-997-5086
Practice Address - Street 1:11525 OLDE CABIN RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7146
Practice Address - Country:US
Practice Address - Phone:314-997-0554
Practice Address - Fax:314-997-5086
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2005031799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
218233OtherBLUE CROSS/BLUE SHIELD
MO000097382OtherMEDICARE LEGACY
Q75609Medicare UPIN
MO000097382OtherMEDICARE LEGACY