Provider Demographics
NPI:1417925850
Name:FRIESE, AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FRIESE
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 1:560 GAGE BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-8650
Mailing Address - Country:US
Mailing Address - Phone:509-942-3286
Mailing Address - Fax:509-628-1354
Practice Address - Street 1:560 GAGE BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-8650
Practice Address - Country:US
Practice Address - Phone:509-942-3627
Practice Address - Fax:509-628-1354
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004387363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1107135Medicaid
WAG8852696Medicare PIN
WAP78848Medicare UPIN