Provider Demographics
NPI:1609989631
Name:AMOROSO, GWYNN (PA)
Entity Type:Individual
Prefix:
First Name:GWYNN
Middle Name:
Last Name:AMOROSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GWYNN
Other - Middle Name:
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2342 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4451
Mailing Address - Country:US
Mailing Address - Phone:215-462-8700
Mailing Address - Fax:215-462-8704
Practice Address - Street 1:2342 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4451
Practice Address - Country:US
Practice Address - Phone:215-462-8700
Practice Address - Fax:215-462-8704
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000920363AM0700X
PAMA051398363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
075594Medicare ID - Type Unspecified