Provider Demographics
NPI:1033255427
Name:SILLICK, MANDY COLLINS (PA-C)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:COLLINS
Last Name:SILLICK
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 1:506 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:COUDERSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16915-1541
Mailing Address - Country:US
Mailing Address - Phone:814-274-0658
Mailing Address - Fax:814-274-8153
Practice Address - Street 1:1001 E 2ND ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-8161
Practice Address - Country:US
Practice Address - Phone:814-260-5471
Practice Address - Fax:814-260-5473
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052865363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA109013JT3OtherMEDICARE
PA109013JT3OtherMEDICARE