Provider Demographics
NPI:1053520544
Name:DEVINE, AMBER D (PA-C)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:D
Last Name:DEVINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:AMBER
Other - Middle Name:DIANE
Other - Last Name:GRAF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:7401 104TH AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7845
Mailing Address - Country:US
Mailing Address - Phone:262-764-5595
Mailing Address - Fax:262-764-9314
Practice Address - Street 1:7401 104TH AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7845
Practice Address - Country:US
Practice Address - Phone:262-764-5595
Practice Address - Fax:262-764-9314
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2180-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical