Provider Demographics
NPI:1124701933
Name:BUNKER, AMANDA LYN (LAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYN
Last Name:BUNKER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MANDALYN
Other - Middle Name:
Other - Last Name:BUNKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:12778 SE STARK ST UNIT 125
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1539
Mailing Address - Country:US
Mailing Address - Phone:503-317-3113
Mailing Address - Fax:
Practice Address - Street 1:12778 SE STARK ST UNIT 125
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:503-317-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC211822171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist