Provider Demographics
NPI:1245331529
Name:ANDERSON, AMANDA JO (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JO
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:STOCKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 17TH AVE E STE 101
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3734
Mailing Address - Country:US
Mailing Address - Phone:320-762-1144
Mailing Address - Fax:320-762-1935
Practice Address - Street 1:111 17TH AVE E STE 101
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3734
Practice Address - Country:US
Practice Address - Phone:320-762-1144
Practice Address - Fax:320-762-1935
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1245331529Medicaid
MA1028592OtherDEA
MA1028592OtherDEA
MN970005486Medicare PIN