Healthcare Provider Details

I. General information

NPI: 1427887629
Provider Name (Legal Business Name): AMANDA BOURNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 WASHINGTON AVE STE 100
ALBANY NY
12206-1098
US

IV. Provider business mailing address

1 KENT PL
WYNANTSKILL NY
12198-8787
US

V. Phone/Fax

Practice location:
  • Phone: 518-459-8106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032090-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: