Provider Demographics
NPI:1528676665
Name:HENDERSON, AMANDA RAY (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAY
Last Name:HENDERSON
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 1:200 LOTHROP ST STE C-800
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-2536
Mailing Address - Country:US
Mailing Address - Phone:412-647-2345
Mailing Address - Fax:
Practice Address - Street 1:200 LOTHROP ST STE C-800
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2536
Practice Address - Country:US
Practice Address - Phone:412-647-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMA063252208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program