Provider Demographics
NPI:1457681900
Name:SEAGRAVES, AMANDA R (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:SEAGRAVES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 ZUBER RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9525
Mailing Address - Country:US
Mailing Address - Phone:614-329-0058
Mailing Address - Fax:
Practice Address - Street 1:5263 NIKE STATION WAY
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-7449
Practice Address - Country:US
Practice Address - Phone:614-878-2100
Practice Address - Fax:614-876-2120
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57804363A00000X
OH50.005061RX363A00000X
FL9105168363L00000X
TX06504363L00000X
TN1913363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner