Provider Demographics
NPI:1063585727
Name:BURKE, AMANDA L (R, MR)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BURKE
Suffix:
Gender:F
Credentials:R, MR
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:R, MR
Mailing Address - Street 1:559 FROST RD
Mailing Address - Street 2:
Mailing Address - City:EVA
Mailing Address - State:AL
Mailing Address - Zip Code:35621-8935
Mailing Address - Country:US
Mailing Address - Phone:256-665-4875
Mailing Address - Fax:
Practice Address - Street 1:1201 13TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4300
Practice Address - Country:US
Practice Address - Phone:256-350-7779
Practice Address - Fax:256-350-2272
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
348484247100000X, 2471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Not Answered2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging