Healthcare Provider Details

I. General information

NPI: 1174901953
Provider Name (Legal Business Name): AMANDA UNALIVIA BURACKER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA ROSE UNALIVIA PA-C

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 HAMAKER CT STE 340
FAIRFAX VA
22031-2237
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 703-849-8036
  • Fax: 703-204-3448
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA2015-0018
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005079
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: