Provider Demographics
NPI:1548548993
Name:MATUSIK, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MATUSIK
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 1:34208 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-4647
Mailing Address - Country:US
Mailing Address - Phone:586-554-7136
Mailing Address - Fax:586-883-9694
Practice Address - Street 1:34208 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-4647
Practice Address - Country:US
Practice Address - Phone:586-554-7136
Practice Address - Fax:586-883-9694
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC021363A00000X
MI5601007420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601007420OtherPHYSICIAN ASSISTANT STATE LICENSE
MI5601007420OtherPHYSICIAN ASSISTANT STATE LICENSE