Provider Demographics
NPI:1528531894
Name:MOCK, AMANDA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:MOCK
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 1:300 STATE ST STE 103A
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1471
Mailing Address - Country:US
Mailing Address - Phone:814-877-8540
Mailing Address - Fax:814-877-8541
Practice Address - Street 1:300 STATE ST STE 103A
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1471
Practice Address - Country:US
Practice Address - Phone:814-877-8540
Practice Address - Fax:814-877-8541
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant