1689861221 NPI number — AMANDA M QUEEN P.A.-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689861221 NPI number — AMANDA M QUEEN P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUEEN
Provider First Name:
AMANDA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689861221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1919 E THOMAS RD
Provider Second Line Business Mailing Address:
BUILDING 2108, SUITE 101
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-7710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-512-8030
Provider Business Mailing Address Fax Number:
602-512-8161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 E THOMAS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-7710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-546-1900
Provider Business Practice Location Address Fax Number:
602-546-1918
Provider Enumeration Date:
09/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  3692 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 321419 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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