Provider Demographics
NPI:1689861221
Name:QUEEN, AMANDA M (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:QUEEN
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 1:1919 E THOMAS RD
Mailing Address - Street 2:BUILDING 2108, SUITE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7710
Mailing Address - Country:US
Mailing Address - Phone:602-512-8030
Mailing Address - Fax:602-512-8161
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-546-1900
Practice Address - Fax:602-546-1918
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ321419Medicaid