MEDICARE: MRS. AMANDA MICHELLE DYER PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	4147	NC

General Provider Information

NPI Number	:	1134362031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA MICHELLE DYER PTA

Provider Business Mailing Address
First Line	:	3608 SHADY ACRES LN TRLR 17
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-8761
Country	:	US
Telephone Number	:	336-575-9513
Fax Number	:

Provider Business Practice Location Address
First Line	:	3608 SHADY ACRES LN TRLR 17
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27127-8761
Country	:	US
Telephone Number	:	336-575-9513
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2009
Last Update Date	:	04/08/2009

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