Provider Demographics
NPI:1003147406
Name:DIAMOND, AMANDA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:DIAMOND
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 1:360 STATION DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7978
Mailing Address - Country:US
Mailing Address - Phone:815-455-7200
Mailing Address - Fax:815-455-9256
Practice Address - Street 1:360 STATION DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7978
Practice Address - Country:US
Practice Address - Phone:815-455-7200
Practice Address - Fax:815-455-9256
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216051001Medicare PIN
IL216053001Medicare PIN