Provider Demographics
NPI:1073055414
Name:AMANDA ANDERSON, MMS, PA-C, PLLC
Entity type:Organization
Organization Name:AMANDA ANDERSON, MMS, PA-C, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMS, PA-C
Authorized Official - Phone:623-321-2221
Mailing Address - Street 1:17505 N 79TH AVE STE 309
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8730
Mailing Address - Country:US
Mailing Address - Phone:623-321-2221
Mailing Address - Fax:855-397-2676
Practice Address - Street 1:17505 N 79TH AVE STE 309
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8730
Practice Address - Country:US
Practice Address - Phone:623-321-2221
Practice Address - Fax:855-397-2676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty