Provider Demographics
NPI:1619286424
Name:ROSENBLUM, AMY WYATT (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:WYATT
Last Name:ROSENBLUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 21975
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4116
Mailing Address - Country:US
Mailing Address - Phone:540-321-4281
Mailing Address - Fax:540-321-4282
Practice Address - Street 1:15237 CREATIVITY DR
Practice Address - Street 2:
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701
Practice Address - Country:US
Practice Address - Phone:540-321-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VADT07529133V00000X
VA363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVS807AOtherMEDICARE
VA1619286424Medicaid