Provider Demographics
NPI:1073194171
Name:SRINIVASAN, AMANDA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:SRINIVASAN
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 1:104 24TH ST S
Mailing Address - Street 2:
Mailing Address - City:BRIGANTINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08203-1834
Mailing Address - Country:US
Mailing Address - Phone:570-401-8016
Mailing Address - Fax:
Practice Address - Street 1:510 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1631
Practice Address - Country:US
Practice Address - Phone:609-383-0200
Practice Address - Fax:609-383-8352
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00615000207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology