Provider Demographics
NPI:1609069814
Name:MADURSKI, AMANDA LEE (OD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:MADURSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:4000 STERRETTANIA RD LOWR LVL
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4125
Practice Address - Country:US
Practice Address - Phone:814-836-0543
Practice Address - Fax:814-838-1145
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001930152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022032200003Medicaid
PA1022032200005Medicaid
PA1022032200004Medicaid
PA1022032200005Medicaid