Provider Demographics
NPI:1669533170
Name:MACALLISTER, AMANDA LOIS (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LOIS
Last Name:MACALLISTER
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 1:1125 E 17TH ST.
Mailing Address - Street 2:N152
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2215
Mailing Address - Country:US
Mailing Address - Phone:714-285-1100
Mailing Address - Fax:714-285-1323
Practice Address - Street 1:8265 W SUNSET BLVD STE 207
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-2470
Practice Address - Country:US
Practice Address - Phone:323-375-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18521Medicaid