Provider Demographics
NPI:1467927764
Name:KUPST, AMANDA MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARY
Last Name:KUPST
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 1:23 TEXACO AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2243
Mailing Address - Country:US
Mailing Address - Phone:607-759-0105
Mailing Address - Fax:
Practice Address - Street 1:500 PORTION RD STE 11
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4587
Practice Address - Country:US
Practice Address - Phone:631-648-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13205879-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty