Provider Demographics
NPI:1760808596
Name:GAYETSKY, AMANDA RAE (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:GAYETSKY
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 OLENTANGY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1576
Mailing Address - Country:US
Mailing Address - Phone:614-754-5500
Mailing Address - Fax:614-457-9519
Practice Address - Street 1:3400 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1576
Practice Address - Country:US
Practice Address - Phone:614-754-5500
Practice Address - Fax:614-754-5501
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-18
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH308940Medicare PIN