Provider Demographics
NPI:1023378874
Name:WIERMANN, AMANDA MARIE (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WIERMANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-0263
Mailing Address - Country:US
Mailing Address - Phone:631-260-1945
Mailing Address - Fax:631-403-1298
Practice Address - Street 1:PO BOX 263
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-0263
Practice Address - Country:US
Practice Address - Phone:631-828-5419
Practice Address - Fax:631-403-1298
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006495363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical