Provider Demographics
NPI:1831497106
Name:PEDOTA, AMANDA LYNN DICK (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN DICK
Last Name:PEDOTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:DICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:14605 NE BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-4130
Mailing Address - Country:US
Mailing Address - Phone:510-910-4924
Mailing Address - Fax:
Practice Address - Street 1:2850 SE POWELL VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-1495
Practice Address - Country:US
Practice Address - Phone:503-666-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21501363A00000X
ORPA183299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant