Provider Demographics
NPI:1669816898
Name:ROY, AMANDA ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:ANN
Last Name:ROY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:712 JAY ST
Mailing Address - City:FOSSIL
Mailing Address - State:OR
Mailing Address - Zip Code:97830
Mailing Address - Country:US
Mailing Address - Phone:541-763-2725
Mailing Address - Fax:541-763-2850
Practice Address - Street 1:712 JAY STREET
Practice Address - Street 2:
Practice Address - City:FOSSIL
Practice Address - State:OR
Practice Address - Zip Code:97830
Practice Address - Country:US
Practice Address - Phone:541-763-2725
Practice Address - Fax:541-763-2850
Is Sole Proprietor?:No
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA161830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant