Basic Information
Provider Information
NPI: 1033557491
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SCHMIDT
FirstName: AMANDA
MiddleName: JOANNE
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1515 COUNTY ROAD B W
Address2:  
City: ROSEVILLE
State: MN
PostalCode: 551136005
CountryCode: US
TelephoneNumber: 8663892727
FaxNumber:  
Practice Location
Address1: 1515 COUNTY ROAD B W
Address2:  
City: ROSEVILLE
State: MN
PostalCode: 551136005
CountryCode: US
TelephoneNumber: 8663892727
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/07/2013
LastUpdateDate: 01/18/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X12251MNY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


Home