Provider Demographics
NPI:1447703079
Name:MACE, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MACE
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 1:420 E NORTH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4746
Mailing Address - Country:US
Mailing Address - Phone:412-359-8850
Mailing Address - Fax:412-359-8878
Practice Address - Street 1:420 E NORTH AVE STE 206
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4746
Practice Address - Country:US
Practice Address - Phone:412-359-8850
Practice Address - Fax:412-359-8878
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058369363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103186310Medicaid
13886957OtherCAQH