Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | SP016405 | PA |
NPI | 1003368770 |
---|---|
Provider Name | Amanda Leah Paczkowski |
First Address | Bethel Park, PA 15102-4200 |
Second Address | Bethel Park, PA 15102-4200 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2016 |
Last Update Date | 15/09/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1034419410001 | (05) | PA |