Provider Demographics
NPI:1053193557
Name:FORTIER, AMANDA LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:FORTIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:KAUKOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 METRO DR STE 460
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1548
Mailing Address - Country:US
Mailing Address - Phone:651-999-7022
Mailing Address - Fax:651-999-6970
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 470
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2773
Practice Address - Country:US
Practice Address - Phone:651-999-6800
Practice Address - Fax:833-905-2114
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant