Provider Demographics
NPI:1720322522
Name:AMSTADT, VALERIE B (PAC)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:B
Last Name:AMSTADT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:B
Other - Last Name:ZANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 3011
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717-3011
Mailing Address - Country:US
Mailing Address - Phone:307-688-3636
Mailing Address - Fax:307-688-7920
Practice Address - Street 1:501 S BURMA AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3426
Practice Address - Country:US
Practice Address - Phone:307-688-3636
Practice Address - Fax:307-688-7920
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3037363A00000X
WYPA611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720322522Medicaid
WI68086 2607Medicare PIN
WI1720322522Medicaid