Provider Demographics
NPI:1326297094
Name:MARKHAM, AMANDA M (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:MARKHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:SCULLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4900 BROAD RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-2265
Mailing Address - Country:US
Mailing Address - Phone:315-492-5535
Mailing Address - Fax:315-492-5222
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5535
Practice Address - Fax:315-492-5222
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335656363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03056200Medicaid
NYP00869152OtherRAILROAD MEDICARE
NYP00869152OtherRAILROAD MEDICARE