Provider Demographics
NPI:1295120962
Name:KISTLER, AMANDA (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KISTLER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3835
Mailing Address - Country:US
Mailing Address - Phone:330-978-4644
Mailing Address - Fax:
Practice Address - Street 1:391 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3835
Practice Address - Country:US
Practice Address - Phone:518-262-5640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3334702086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty