Provider Demographics
NPI:1982055026
Name:PROBASCO, AMANDA MARGARET (PA)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MARGARET
Last Name:PROBASCO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARGARET
Other - Last Name:BATTERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2759
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-2759
Mailing Address - Country:US
Mailing Address - Phone:920-830-5900
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:800 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1943
Practice Address - Country:US
Practice Address - Phone:920-364-3600
Practice Address - Fax:920-364-3900
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400320873Medicare Oscar/Certification
WIK400320881Medicare Oscar/Certification