Provider Demographics
NPI:1689122368
Name:PETZOLD, AMANDA CHRISTENA (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CHRISTENA
Last Name:PETZOLD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:CHRISTENA
Other - Last Name:SHUMAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1015 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-2556
Mailing Address - Country:US
Mailing Address - Phone:989-754-3000
Mailing Address - Fax:989-754-3015
Practice Address - Street 1:1015 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2556
Practice Address - Country:US
Practice Address - Phone:989-754-3000
Practice Address - Fax:989-754-3015
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant