Provider Demographics
NPI:1851584593
Name:CONNAN, AMANDA GRAY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRAY
Last Name:CONNAN
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:PO BOX 561600
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1600
Mailing Address - Country:US
Mailing Address - Phone:321-434-4600
Mailing Address - Fax:321-259-0635
Practice Address - Street 1:8725 N WICKHAM RD
Practice Address - Street 2:SUITE 302
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2239
Practice Address - Country:US
Practice Address - Phone:321-434-9230
Practice Address - Fax:321-434-9231
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005133363AM0700X
FLPA9106972363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I970009Medicare PIN
AL510I970033Medicare PIN
FLGR440ZMedicare PIN