Provider Demographics
NPI:1427634468
Name:OLIVER, AMANDA SHERMAINE (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHERMAINE
Last Name:OLIVER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILFORD HALL LOOP BLDG 455459
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-916-9928
Mailing Address - Fax:210-916-9332
Practice Address - Street 1:10 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT AFB
Practice Address - State:ND
Practice Address - Zip Code:58705-5003
Practice Address - Country:US
Practice Address - Phone:701-723-5221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-21
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207543208D00000X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program