Provider Demographics
NPI:1578803813
Name:CRUZ, AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CRUZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 JAMESTOWN CIR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2138
Mailing Address - Country:US
Mailing Address - Phone:203-623-0803
Mailing Address - Fax:
Practice Address - Street 1:1305 YORK AVE FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5663
Practice Address - Country:US
Practice Address - Phone:212-746-2363
Practice Address - Fax:646-962-0118
Is Sole Proprietor?:No
Enumeration Date:2013-02-24
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016042363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant