Provider Demographics
NPI:1528545548
Name:AUSTIN, AMANDA MARI (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARI
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 THORNDIKE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-2742
Mailing Address - Country:US
Mailing Address - Phone:339-364-9791
Mailing Address - Fax:
Practice Address - Street 1:281 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2925
Practice Address - Country:US
Practice Address - Phone:212-420-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant