Provider Demographics
NPI:1134431158
Name:KATY, AMANDA S (PAC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:S
Last Name:KATY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4201 SAINT ANTOINE ST
Mailing Address - Street 2:SUITE 3R
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-745-3330
Mailing Address - Fax:313-745-3653
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 3R
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-3330
Practice Address - Fax:313-745-3653
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA055272363A00000X
MI5601005738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant