Provider Demographics
NPI:1538422431
Name:RIVER, AMANDA SUE (MD, MPH)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:RIVER
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:RIVER
Other - Middle Name:AMANDASUE
Other - Last Name:BOUSKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:1433 PALE SAN VITORES ROAD UNIT 707
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:671-645-5500
Mailing Address - Fax:
Practice Address - Street 1:133 ROUTE 3
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-6911
Practice Address - Country:US
Practice Address - Phone:671-645-5500
Practice Address - Fax:671-645-5549
Is Sole Proprietor?:No
Enumeration Date:2012-06-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171188207P00000X
AZR73294207P00000X
OK32158207P00000X
GUM-2039207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH109960Medicaid