Provider Demographics
NPI:1033557236
Name:GANDERT, AMANDA I (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:I
Last Name:GANDERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:I
Other - Last Name:WELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1167 INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1069 DELAWARE AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-1400
Practice Address - Country:US
Practice Address - Phone:740-387-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.003772RXOtherOHIO MEDICAL BOARD
OH003772OtherLICENSE