Basic Information
| Provider Information | |||||||||
| NPI: | 1184687600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | METHVIN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | PHELPS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHELPS | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1069 POWDERMILL HILL ROAD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312793377 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 326 N LOCUST AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384643516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317629797 | ||||||||
| FaxNumber: | 9317629798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA1430 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 20431 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1508540 | 05 | TN | MEDICAID |