Provider Demographics
NPI:1992980007
Name:WAXMAN, AMY DIANE (ARNP)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:DIANE
Last Name:WAXMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 NW 49TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33313-7266
Mailing Address - Country:US
Mailing Address - Phone:954-731-1101
Mailing Address - Fax:
Practice Address - Street 1:3001 NW 49TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7266
Practice Address - Country:US
Practice Address - Phone:954-731-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2754072363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS88570Medicare UPIN