Provider Demographics
NPI:1063599652
Name:HETTRICH, AMY L (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:HETTRICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 569
Mailing Address - Street 2:848 ROUTE 50
Mailing Address - City:BURNT HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:12027-0569
Mailing Address - Country:US
Mailing Address - Phone:518-831-1500
Mailing Address - Fax:518-377-1677
Practice Address - Street 1:848 ROUTE 50
Practice Address - Street 2:
Practice Address - City:BURNT HILLS
Practice Address - State:NY
Practice Address - Zip Code:12027
Practice Address - Country:US
Practice Address - Phone:518-831-1500
Practice Address - Fax:518-377-1677
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005898363A00000X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02554974Medicaid
S73014Medicare UPIN
NY02554974Medicaid
NYBB3836Medicare ID - Type Unspecified