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: | 06/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50.003772RX | 01 | OH | OHIO MEDICAL BOARD | OTHER | 003772 | 01 | OH | LICENSE | OTHER |