Provider Demographics
NPI:1619342243
Name:ROSS, AMANDA (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:PPM
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-261-6034
Mailing Address - Fax:315-261-6025
Practice Address - Street 1:49 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1889
Practice Address - Country:US
Practice Address - Phone:315-274-9075
Practice Address - Fax:315-274-9078
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY340200363LF0000X
MI4704287960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily