Provider Demographics
NPI:1669765087
Name:SURGUINE, AMANDA MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:SURGUINE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:SCHWARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:8305 FALLS OF NEUSE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8305 FALLS OF NEUSE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3546
Practice Address - Country:US
Practice Address - Phone:919-870-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5794225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant