Provider Demographics
NPI:1346790151
Name:EVANGELISTA, AMANDA LYN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:LYN
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 MILL ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-1045
Mailing Address - Country:US
Mailing Address - Phone:631-258-2404
Mailing Address - Fax:
Practice Address - Street 1:34 MILL ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1045
Practice Address - Country:US
Practice Address - Phone:631-258-2404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020210363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant