Provider Demographics
NPI:1437191715
Name:PIDGEON, AMANDA (RPAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PIDGEON
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SERNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPAC
Mailing Address - Street 1:STONY BROOK UNIVERSITY MEDICAL CTR
Mailing Address - Street 2:HSC LEVEL 12, RM 080
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8122
Mailing Address - Country:US
Mailing Address - Phone:631-444-1116
Mailing Address - Fax:631-444-1535
Practice Address - Street 1:STONY BROOK UNIVERSITY MEDICAL CTR
Practice Address - Street 2:HSC LEVEL 12, RM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8122
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:631-444-1535
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010224363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY569711Medicare ID - Type Unspecified