Provider Demographics
NPI:1043974637
Name:MUCK, AMANDA SUZANNE ANUENUE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUZANNE ANUENUE
Last Name:MUCK
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 1:930 E 15TH ST APT 510
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5875
Mailing Address - Country:US
Mailing Address - Phone:972-979-3983
Mailing Address - Fax:
Practice Address - Street 1:5228 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5005
Practice Address - Country:US
Practice Address - Phone:972-250-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15075363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA15075OtherTEXAS MEDICAL BOARD