Provider Demographics
NPI:1801048103
Name:MAZZETTA, AMANDA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MAZZETTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:TIRADO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1075 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066
Mailing Address - Country:US
Mailing Address - Phone:732-574-1399
Mailing Address - Fax:732-574-1433
Practice Address - Street 1:1075 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066
Practice Address - Country:US
Practice Address - Phone:732-574-1399
Practice Address - Fax:732-574-1433
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00208400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ159160TL9Medicare PIN