Provider Demographics
NPI:1972100949
Name:ALCANTAR, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ALCANTAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BERTHIAUME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8822 W MINNEZONA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-1499
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8822 W MINNEZONA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-1499
Practice Address - Country:US
Practice Address - Phone:602-857-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8232OtherSTATE LICENSE NUMBER