Provider Demographics
NPI:1669574943
Name:SMITH, AMANDA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5913 N COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2014
Mailing Address - Country:US
Mailing Address - Phone:360-461-3933
Mailing Address - Fax:
Practice Address - Street 1:9900 SE SUNNYSIDE RD
Practice Address - Street 2:SUNNYBROOK MEDICAL OFFICE
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9777
Practice Address - Country:US
Practice Address - Phone:503-786-8435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR PA01036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant