Healthcare Provider Details

I. General information

NPI: 1437589124
Provider Name (Legal Business Name): AMANDA J ROBERTSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S VAN BUREN ST
GREEN BAY WI
54301-3526
US

IV. Provider business mailing address

4565 HILLTOP DR
SUAMICO WI
54173-8428
US

V. Phone/Fax

Practice location:
  • Phone: 414-290-6720
  • Fax: 414-290-6755
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4063-23
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1507-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: