Basic Information
| Provider Information | |||||||||
| NPI: | 1285671032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTMORELAND | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KETTNER | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 820 ARBUTUS AVE | ||||||||
| Address2: | |||||||||
| City: | OCONTO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541532004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208351100 | ||||||||
| FaxNumber: | 9208351099 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 ARBUTUS AVE | ||||||||
| Address2: | |||||||||
| City: | OCONTO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541532004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208351100 | ||||||||
| FaxNumber: | 9208351099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1979 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1979 | 01 | WI | LICENSE | OTHER |