Provider Demographics
NPI:1083024277
Name:BERNATH, AMANDA BORN (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:BORN
Last Name:BERNATH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BORN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:100 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:715-524-2161
Practice Address - Fax:715-526-3461
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI65840207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program