Provider Demographics
NPI:1205966975
Name:STEVENSON-CALI, AMANDA JUDITH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JUDITH
Last Name:STEVENSON-CALI
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JUDITH
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6308
Mailing Address - Fax:
Practice Address - Street 1:905 VERDAE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4029
Practice Address - Country:US
Practice Address - Phone:864-286-7550
Practice Address - Fax:864-286-7551
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA61116067OtherMEDICARE PTAN
SCAA61116121OtherMEDICARE PTAN
SCAA61118510OtherMEDICARE PIN
SC1103PAMedicaid
SCAA61116067OtherMEDICARE PTAN
SCAA61119068OtherMEDIARE PIN
SCAA61116067OtherMEDICARE PTAN
SCAA61118510Medicare PIN