Healthcare Provider Details

I. General information

NPI: 1053897850
Provider Name (Legal Business Name): AMANDA WREGGELSWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2018
Last Update Date: 07/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 WILMINGTON AVE
NEW CASTLE PA
16105-2516
US

IV. Provider business mailing address

3613 SILVANA TERRACE RD
STANWOOD WA
98292-9004
US

V. Phone/Fax

Practice location:
  • Phone: 724-658-9001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: