Provider Demographics
NPI:1053936088
Name:OEDER, AMANDA LYNN (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:OEDER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 E BROADWAY APT 420
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-8183
Mailing Address - Country:US
Mailing Address - Phone:920-492-9201
Mailing Address - Fax:
Practice Address - Street 1:N16W24131 RIVERWOOD DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1106
Practice Address - Country:US
Practice Address - Phone:262-696-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5504363A00000X
COPA.0009263363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program