Provider Demographics
NPI:1528386489
Name:LAVIN, AMANDA BROOKE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:BROOKE
Last Name:LAVIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2301 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3542
Mailing Address - Country:US
Mailing Address - Phone:215-952-9559
Mailing Address - Fax:215-952-9615
Practice Address - Street 1:2301 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-952-9559
Practice Address - Fax:215-952-9615
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-17
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA053731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant