Provider Demographics
NPI:1689974289
Name:AMIANDA, ERICA (PA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:AMIANDA
Suffix:
Gender:F
Credentials:PA
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 1517
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-1517
Mailing Address - Country:US
Mailing Address - Phone:551-996-4424
Mailing Address - Fax:
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 703
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:551-996-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014376363A00000X
NJ25MP00283800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant