Provider Demographics
NPI:1003193202
Name:FIDIAM, AMANDA LYN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYN
Last Name:FIDIAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:LYN
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:340 MONTAGE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1782
Mailing Address - Country:US
Mailing Address - Phone:570-346-3686
Mailing Address - Fax:570-558-6838
Practice Address - Street 1:340 MONTAGE MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1782
Practice Address - Country:US
Practice Address - Phone:570-346-3686
Practice Address - Fax:570-558-6838
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055142363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical