Provider Demographics
NPI:1043939572
Name:DOTY, AMANDA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:DOTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HAMPSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 HAMPSHIRE DR
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2121
Practice Address - Country:US
Practice Address - Phone:516-761-9874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant