1497828693 NPI number — AMANDA L. MISHRA CNS

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 1497828693 NPI number — AMANDA L. MISHRA CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISHRA
Provider First Name:
AMANDA
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNS
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1497828693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 STARK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78756-1508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-452-2506
Provider Business Mailing Address Fax Number:
512-371-0187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 STARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78756-1508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-452-2506
Provider Business Practice Location Address Fax Number:
512-371-0187
Provider Enumeration Date:
11/16/2006

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: 364SC1501X , with the licence number:  690685 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364S00000X , with the licence number: 690685 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 215039302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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