Provider Demographics
NPI:1861506370
Name:DEDEA, AMY LARISSA (PHARMD, PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LARISSA
Last Name:DEDEA
Suffix:
Gender:F
Credentials:PHARMD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 CANYON TRL
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86351-7705
Mailing Address - Country:US
Mailing Address - Phone:928-773-2525
Mailing Address - Fax:
Practice Address - Street 1:12075 AZ-69
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327
Practice Address - Country:US
Practice Address - Phone:928-772-1673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018219183500000X
FLPS38830183500000X
CT2405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183500000XPharmacy Service ProvidersPharmacist