Provider Demographics
NPI:1568771533
Name:WRIGHT, AMANDA R (PA-AA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA-AA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:1255 HIGHWAY 54 WEST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4548
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL20367H00000X
GA006561367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA0016Medicaid
SCP00897043OtherRAILROAD MEDICARE
SCP00897043OtherRAILROAD MEDICARE