Provider Demographics
NPI:1831113877
Name:MEDICK, AMANDA LAURA (MSPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LAURA
Last Name:MEDICK
Suffix:
Gender:F
Credentials:MSPT
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 630
Mailing Address - Street 2:
Mailing Address - City:EAST GREENBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12061-0630
Mailing Address - Country:US
Mailing Address - Phone:518-233-0544
Mailing Address - Fax:518-233-0703
Practice Address - Street 1:1 WEST AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-6045
Practice Address - Country:US
Practice Address - Phone:518-583-7537
Practice Address - Fax:518-583-7606
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025408-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA0015Medicare ID - Type Unspecified