Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | SP019368 | PA |
N | 363LF0000X | Nurse Practitioner - Family Medicine | RN57822 | PA |
NPI | 1003396821 |
---|---|
Provider Name | Amanda L. Roeder |
First Address | Pittsburgh, PA 15203-2348 |
Second Address | Ellwood City, PA 16117-5513 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2018 |
Last Update Date | 15/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
SP019368 | NURSE PRACTITIONER LICENSE (01) | PA |