Healthcare Provider Details

I. General information

NPI: 1336581115
Provider Name (Legal Business Name): AMANDA E MARENGO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 FAIRMOUNT AVE
JAMESTOWN NY
14701
US

IV. Provider business mailing address

816 FAIRMOUNT AVE
JAMESTOWN NY
14701
US

V. Phone/Fax

Practice location:
  • Phone: 716-664-2589
  • Fax: 716-483-3050
Mailing address:
  • Phone: 716-664-2589
  • Fax: 716-483-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number016744-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number016744
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: