Healthcare Provider Details

I. General information

NPI: 1578803813
Provider Name (Legal Business Name): AMANDA CRUZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2013
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 YORK AVE FL 9
NEW YORK NY
10021-5663
US

IV. Provider business mailing address

9 JAMESTOWN CIR
WALLINGFORD CT
06492-2138
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-2363
  • Fax: 646-962-0118
Mailing address:
  • Phone: 203-623-0803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number016042
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: