Provider Demographics
NPI:1275034258
Name:SIEGEL, AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SIEGEL
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 1:12227 N MAINSTREET UNIT 3
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8501
Mailing Address - Country:US
Mailing Address - Phone:909-964-4816
Mailing Address - Fax:
Practice Address - Street 1:5569 GRASSY MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-8220
Practice Address - Country:US
Practice Address - Phone:909-883-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55389363A00000X
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant