Provider Demographics
NPI:1477888345
Name:STROM, AMANDA B (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:STROM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:B
Other - Last Name:KNUTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53182-1328
Mailing Address - Country:US
Mailing Address - Phone:262-878-4424
Mailing Address - Fax:
Practice Address - Street 1:1120 MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:WI
Practice Address - Zip Code:53182-1328
Practice Address - Country:US
Practice Address - Phone:262-878-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2516363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical