Provider Demographics
NPI:1851661128
Name:STARTUP, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:STARTUP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:OUTLOOK
Mailing Address - State:WA
Mailing Address - Zip Code:98938-9570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:OUTLOOK
Practice Address - State:WA
Practice Address - Zip Code:98938-9570
Practice Address - Country:US
Practice Address - Phone:206-465-6807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201140769RN390200000X
WAAP60442329367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program