1770702201 NPI number — AMANDA N GUDGELL DO

Table of content: AMANDA N GUDGELL DO (NPI 1770702201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770702201 NPI number — AMANDA N GUDGELL DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUDGELL
Provider First Name:
AMANDA
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVIS
Provider Other First Name:
AMANDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770702201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1130 W 4TH ST
Provider Second Line Business Mailing Address:
SUITE 2001
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66044-1328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-505-3205
Provider Business Mailing Address Fax Number:
785-505-5261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1130 W 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 2001
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66044-1328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-505-3205
Provider Business Practice Location Address Fax Number:
785-505-5261
Provider Enumeration Date:
04/24/2007

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: 207RP1001X , with the licence number:  533862 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200680380B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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