Healthcare Provider Details

I. General information

NPI: 1073093050
Provider Name (Legal Business Name): AMANDA KATHERINE GAUTHIER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2018
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 MACK RD
FAIRFIELD OH
45014-5335
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 513-870-7000
  • Fax:
Mailing address:
  • Phone: 800-828-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005639RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: