Provider Demographics
NPI:1154307759
Name:CANAVAN, AMANDA WOJEWODKA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:WOJEWODKA
Last Name:CANAVAN
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 1:4755 OGLETOWN STANTON RD STE 2670
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:302-733-2438
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 2670
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-2438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001255363A00000X
PAMA054081363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA099588Medicare PIN