Provider Demographics
NPI:1902343429
Name:JOHNSON, AMANDA KRISTINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KRISTINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:KRISTINE
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-4000
Practice Address - Fax:570-621-9213
Is Sole Proprietor?:No
Enumeration Date:2017-01-22
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058793363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant