Provider Demographics
NPI:1861689234
Name:AMAR- EICHENWALD, JOHANNA (PA)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:
Last Name:AMAR- EICHENWALD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E PALISADE AVE APT 19H
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3161
Mailing Address - Country:US
Mailing Address - Phone:718-371-8556
Mailing Address - Fax:
Practice Address - Street 1:240 E PALISADE AVE APT 19H
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3161
Practice Address - Country:US
Practice Address - Phone:718-371-8556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant