Provider Demographics
NPI:1427887629
Name:BOURNE, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BOURNE
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 1:1 KENT PL
Mailing Address - Street 2:
Mailing Address - City:WYNANTSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12198-8787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1365 WASHINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1098
Practice Address - Country:US
Practice Address - Phone:518-459-8106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032090-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant