Provider Demographics
NPI:1326509753
Name:WALD, AMANDA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WALD
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:4225 GOLDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4215
Mailing Address - Country:US
Mailing Address - Phone:763-427-8320
Mailing Address - Fax:
Practice Address - Street 1:3833 COON RAPIDS BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2697
Practice Address - Country:US
Practice Address - Phone:763-427-8320
Practice Address - Fax:763-302-4338
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2022-05-19
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Provider Licenses
StateLicense IDTaxonomies
MN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant