Provider Demographics
NPI:1922502947
Name:MATTINGLEY, AMANDA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:MATTINGLEY
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 1:2900 HANNAH BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5382
Mailing Address - Country:US
Mailing Address - Phone:517-364-8100
Mailing Address - Fax:
Practice Address - Street 1:2900 HANNAH BLVD STE 216
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-364-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009055363AS0400X
PAMA059741363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical