Provider Demographics
NPI:1386122869
Name:DOUGLAS, AMANDA N (PA-C)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:N
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1908 N BEALE RD STE E
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-6937
Mailing Address - Country:US
Mailing Address - Phone:530-743-6888
Mailing Address - Fax:530-743-9823
Practice Address - Street 1:1908 N BEALE RD STE E
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-6937
Practice Address - Country:US
Practice Address - Phone:530-743-6888
Practice Address - Fax:530-743-9823
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant