Provider Demographics
NPI:1316341902
Name:PERSONS, AMANDA L (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:PERSONS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:HEWLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14214 CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13648
Mailing Address - Country:US
Mailing Address - Phone:315-537-5041
Mailing Address - Fax:315-537-5037
Practice Address - Street 1:14214 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:NY
Practice Address - Zip Code:13648
Practice Address - Country:US
Practice Address - Phone:315-537-5041
Practice Address - Fax:315-537-5037
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant