Basic Information
Provider Information | |||||||||
NPI: | 1215332515 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ADAIR | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | BETHANY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUMMO | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | BETHANY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7 DOCK HILL RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLEBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178428910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708372123 | ||||||||
FaxNumber: | 5708372185 | ||||||||
Practice Location | |||||||||
Address1: | 75 E DERRY RD | ||||||||
Address2: |   | ||||||||
City: | HERSHEY | ||||||||
State: | PA | ||||||||
PostalCode: | 170332705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7178350700 | ||||||||
FaxNumber: | 7178350702 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2014 | ||||||||
LastUpdateDate: | 12/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA003618 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 103181664 | 05 | PA |   | MEDICAID |