Provider Demographics
NPI:1659312403
Name:DIEFENDERFER, AMANDA C (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:C
Last Name:DIEFENDERFER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 E KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1607
Mailing Address - Country:US
Mailing Address - Phone:316-685-2221
Mailing Address - Fax:316-634-3058
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-685-2221
Practice Address - Fax:316-634-3058
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY20165Medicare ID - Type Unspecified
WYQ36836Medicare UPIN