Provider Demographics
NPI:1679984694
Name:DAGOSTINO, AMBER M (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:M
Last Name:DAGOSTINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:M
Other - Last Name:BOWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-731-0101
Mailing Address - Fax:717-731-8359
Practice Address - Street 1:1000 N FRONT ST
Practice Address - Street 2:
Practice Address - City:WORMLEYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17043-1034
Practice Address - Country:US
Practice Address - Phone:717-731-0101
Practice Address - Fax:717-731-8359
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056906363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103379890Medicaid