Provider Demographics
NPI:1912661505
Name:MCDERMOTT, AMANDA LEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SCOTT LN
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5433
Mailing Address - Country:US
Mailing Address - Phone:315-663-5145
Mailing Address - Fax:
Practice Address - Street 1:104 UNION AVE STE 904
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1845
Practice Address - Country:US
Practice Address - Phone:315-703-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY347686363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily