Provider Demographics
NPI:1114586112
Name:FERGUSON, AMANDA VY-LYN (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:VY-LYN
Last Name:FERGUSON
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 1:1620 N ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-1926
Mailing Address - Country:US
Mailing Address - Phone:909-576-9050
Mailing Address - Fax:
Practice Address - Street 1:814 FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2530
Practice Address - Country:US
Practice Address - Phone:909-576-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant