Basic Information
| Provider Information | |||||||||
| NPI: | 1578947289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HASSEY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | COLEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PALLISTER | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | COLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12 COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189401102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152982694 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 615 W GERMANTOWN PIKE # 100 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103978615 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2015 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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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 | 152W00000X | OEG003064 | PA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 13584914 | 01 | PA | CAQH NUMBER | OTHER |