Basic Information
| Provider Information | |||||||||
| NPI: | 1386715399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TIPTON | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3555 HARDEN STREET EXT | ||||||||
| Address2: | 15 MEDICAL PARK | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035455017 | ||||||||
| FaxNumber: | 8032553451 | ||||||||
| Practice Location | |||||||||
| Address1: | 3209 COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346113 | ||||||||
| FaxNumber: | 8034344277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 12/03/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 103939 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2373 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8901642 | 05 | NC | MEDICAID | 2288PA | 05 | SC | MEDICAID |