Provider Demographics
NPI:1134907975
Name:GIST, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GIST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10507 CYPRESS TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-5038
Mailing Address - Country:US
Mailing Address - Phone:562-508-6996
Mailing Address - Fax:
Practice Address - Street 1:125 E COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2101
Practice Address - Country:US
Practice Address - Phone:321-841-7090
Practice Address - Fax:321-843-2267
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9117898363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical