Provider Demographics
NPI:1154634780
Name:WINTERBOER, AMANDA ANN (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:ANN
Last Name:WINTERBOER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ANN
Other - Last Name:MESNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 243
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-0243
Mailing Address - Country:US
Mailing Address - Phone:712-262-3331
Mailing Address - Fax:712-262-6885
Practice Address - Street 1:110 W 4TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-3858
Practice Address - Country:US
Practice Address - Phone:712-262-3331
Practice Address - Fax:712-262-6885
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-25
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1154634780Medicaid
IAP00873784Medicare PIN
IA6487260001Medicare NSC
IA1154634780Medicaid