Provider Demographics
NPI:1588909659
Name:WARD, AMANDA JEANETTE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEANETTE
Last Name:WARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEANETTE
Other - Last Name:ECKLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:915 BENNER PIKE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7395
Mailing Address - Country:US
Mailing Address - Phone:814-867-7030
Mailing Address - Fax:814-867-7032
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-272-0579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055829363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA274663Q9ZMedicare PIN