Provider Demographics
NPI:1083926802
Name:LOIS, AMANDA SUE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUE
Last Name:LOIS
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 1:700 E BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-2201
Mailing Address - Country:US
Mailing Address - Phone:650-294-0792
Mailing Address - Fax:
Practice Address - Street 1:700 E BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2201
Practice Address - Country:US
Practice Address - Phone:650-294-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018516363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04179062Medicaid
NY04179062Medicaid