Provider Demographics
NPI:1285671032
Name:WESTMORELAND, AMANDA K (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
Last Name:WESTMORELAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:K
Other - Last Name:KETTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:820 ARBUTUS AVE
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-2004
Mailing Address - Country:US
Mailing Address - Phone:920-835-1100
Mailing Address - Fax:920-835-1099
Practice Address - Street 1:820 ARBUTUS AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-2004
Practice Address - Country:US
Practice Address - Phone:920-835-1100
Practice Address - Fax:920-835-1099
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1979363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1979OtherLICENSE
P00697642Medicare Oscar/Certification
WI430751193Medicare Oscar/Certification
WI1979OtherLICENSE
000013Medicare Oscar/Certification
WI000022Medicare Oscar/Certification