Provider Demographics
NPI:1891061321
Name:MIRCHEL, AMANDA ELISE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELISE
Last Name:MIRCHEL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ELISE
Other - Last Name:MIRCHEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4927
Mailing Address - Country:US
Mailing Address - Phone:631-572-0039
Mailing Address - Fax:631-376-3798
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-572-0039
Practice Address - Fax:631-376-3798
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23015488363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant