Provider Demographics
NPI:1710720347
Name:WASSERMAN, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WASSERMAN
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 1:210 E 64TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7471
Mailing Address - Country:US
Mailing Address - Phone:973-303-6946
Mailing Address - Fax:
Practice Address - Street 1:210 E 64TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7471
Practice Address - Country:US
Practice Address - Phone:973-303-6946
Practice Address - Fax:646-785-8121
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032028363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY032028OtherNY STATE LICENSE
NJ25MP00863400OtherNEW JERSEY STATE LICENSE