Basic Information
| Provider Information | |||||||||
| NPI: | 1083785695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASIONGALE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8717 W 110TH ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134282900 | ||||||||
| FaxNumber: | 9134282951 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 SE BLUE PKWY | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134282900 | ||||||||
| FaxNumber: | 9134282951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 43-557644 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN101263 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 2018044045 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 339446 | 01 | GA | WELLCARE CMO | OTHER | 430079467 | 01 | GA | RRMEDICARE | OTHER | GAN227 | 05 | SC | MEDICAID | 000731607C | 05 | GA | MEDICAID | 000731607D | 05 | GA | MEDICAID | 550789920 | 01 | GA | TRICARE | OTHER |