Provider Demographics
NPI:1780985630
Name:HATALSKI, AMANDA LYNNE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNNE
Last Name:HATALSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:4 SILVERSTEIN
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2626
Mailing Address - Fax:215-349-8195
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:4 SILVERSTEIN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2626
Practice Address - Fax:215-349-8195
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053418363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-2359401OtherMAIN LINE HEALTHCARE TAX ID