1780894675 NPI number — MRS. AMANDA L FERGUSON MT-BC, NMT

Table of content: MRS. AMANDA L FERGUSON MT-BC, NMT (NPI 1780894675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780894675 NPI number — MRS. AMANDA L FERGUSON MT-BC, NMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
AMANDA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MT-BC, NMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURKART
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:
1780894675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16410 S 12TH ST
Provider Second Line Business Mailing Address:
# 109
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85048-4001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-478-0287
Provider Business Mailing Address Fax Number:
480-659-1726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2702 N 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 1000
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85004-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-840-6410
Provider Business Practice Location Address Fax Number:
602-840-6431
Provider Enumeration Date:
05/22/2007

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: 225A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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