Provider Demographics
NPI:1508377060
Name:DAVIS, AMANDA SUE
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:SUE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1412-22 FAIRMOUNT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-684-5344
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:1412 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2908
Practice Address - Country:US
Practice Address - Phone:215-235-9600
Practice Address - Fax:215-684-5360
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2019-08-21
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant