Provider Demographics
NPI:1326109208
Name:RODRIGUEZ, AMANDA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:M
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:LAMBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:300 W WASHINGTON AVE STE 250
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2160
Practice Address - Country:US
Practice Address - Phone:517-539-3188
Practice Address - Fax:517-539-3189
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004537363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN9768002Medicare UPIN