Provider Demographics
NPI:1437640034
Name:PAULSGROVE, AMANDA PHAM
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:PHAM
Last Name:PAULSGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KHANH
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2541 TRACY AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2937
Mailing Address - Country:US
Mailing Address - Phone:405-496-6848
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-20
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557595-061367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered