Provider Demographics
NPI:1669646808
Name:CZARNECKI, AMANDA MARIE (PA-C, MMS)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:CZARNECKI
Suffix:
Gender:F
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 COPPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7059
Mailing Address - Country:US
Mailing Address - Phone:888-632-0542
Mailing Address - Fax:
Practice Address - Street 1:751 SAPPINGTON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2354
Practice Address - Country:US
Practice Address - Phone:573-468-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008013234363A00000X, 363A00000X
IL085006964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156580026Medicare PIN
MO150050003Medicare PIN
MO132130001Medicare PIN