Provider Demographics
NPI:1144699653
Name:MAIN, AMANDA IRENE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:IRENE
Last Name:MAIN
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 1:500 WINDERLEY PL STE 115
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7406
Mailing Address - Country:US
Mailing Address - Phone:407-875-0555
Mailing Address - Fax:
Practice Address - Street 1:500 WINDERLEY PL STE 115
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7406
Practice Address - Country:US
Practice Address - Phone:407-875-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027177363A00000X
FLPAT9108927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant