NPIMap

Organization Active NPI

Amanda K Nixon PA-C PC

  • Rural Health Clinic/Center
  • Tustin, MI
National Provider Identifier
1578072591
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
AMANDA K NIXON PA-C PC
Practice address
202 Howard St
Tustin, MI 49688-5123
Phone
(231) 465-4165
Fax
(231) 465-4315
NPI assigned
Sep 21, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Amanda K Nixon, PA-CNPI 1912250861
Title
Owner
Phone
(231) 465-4165

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

202 Howard St
Tustin, MI 49688-5123

Mailing address

PO Box 74
Tustin, MI 49688-0074
Phone (231) 465-4165

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20170731003739 MI Part B Supplier - Clinic/Group Practice 4587935192 Receives reassigned benefits from 2 practitioners
1 other NPI on this enrollment
Practice locations: Tustin, MI
O20171219000059 MI Part A Provider - Rural Health Clinic 4587935192 Practice locations: Tustin, MI

Rural health clinic certification: CCN 238934

Legal name
AMANDA K NIXON PA-C PC
Doing business as
AMANDA'S FAMILY MEDICINE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 18, 2019
Last certification
Jul 18, 2019
Ownership / control type
2B
Organization structure
CorporationProprietary
Incorporated
Apr 5, 2017 in MI
Enrollment address
202 S Howard St
Tustin, MI 49688-5123

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

111 S Higbee St
Reed City, MI 49677
Phone (231) 465-4165

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jonathan a Dennis Individual 5% Or Greater Direct Ownership Interest Oct 1, 2017 5%
Amanda K Nixon Individual 5% Or Greater Direct Ownership Interest Oct 1, 2017 95%
W-2 Managing EmployeeOwner Oct 1, 2017

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1505952000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1578072591",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 74",
            "city": "TUSTIN",
            "state": "MI",
            "postal_code": "496880074",
            "telephone_number": "231-465-4165",
            "fax_number": "231-465-4165"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "202 HOWARD ST",
            "city": "TUSTIN",
            "state": "MI",
            "postal_code": "496885123",
            "telephone_number": "231-465-4165",
            "fax_number": "231-465-4315"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AMANDA K NIXON PA-C PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-21",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "NIXON",
        "authorized_official_first_name": "AMANDA",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "231-465-4165",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "PA-C"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tustin, MI

Sources for this page

Verify at the official NPI Registry.