Basic Information
Provider Information
NPI: 1033557236
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GANDERT
FirstName: AMANDA
MiddleName: I
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: WELLER
OtherFirstName: AMANDA
OtherMiddleName: I
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: PA-C
OtherLastNameType: 1
Mailing Information
Address1: 1167 INDEPENDENCE AVE
Address2: SUITE 205
City: MARION
State: OH
PostalCode: 433026360
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1069 DELAWARE AVE
Address2: SUITE 205
City: MARION
State: OH
PostalCode: 433021400
CountryCode: US
TelephoneNumber: 7403874578
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/10/2013
LastUpdateDate: 08/12/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X  Y Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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