Provider Demographics
NPI:1619951985
Name:VON DER SCHULENBURG, AMANDA GRAEFIN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:GRAEFIN
Last Name:VON DER SCHULENBURG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LORIS
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5673 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 870
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-255-2975
Mailing Address - Fax:404-255-2276
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 870
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-255-2975
Practice Address - Fax:404-255-2276
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003997363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA498718801AMedicaid
97WCDLPMedicare PIN
GA498718801AMedicaid