Healthcare Provider Details

I. General information

NPI: 1831497106
Provider Name (Legal Business Name): AMANDA LYNN DICK PEDOTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA LYNN DICK PA-C

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL VALLEY RD STE 100
GRESHAM OR
97080-1495
US

IV. Provider business mailing address

14605 NE BROADWAY
PORTLAND OR
97230-4130
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5050
  • Fax:
Mailing address:
  • Phone: 510-910-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21501
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA183299
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: