Provider Demographics
NPI:1699074823
Name:TROUT, AMANDA C (DO)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:TROUT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 AVENIDA PONCE DE LEON
Mailing Address - Street 2:STE 205- PMB#10600
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00906
Mailing Address - Country:US
Mailing Address - Phone:847-275-5961
Mailing Address - Fax:
Practice Address - Street 1:954 AVENIDA PONCE DE LEON
Practice Address - Street 2:STE 205- PMB#10600
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00906
Practice Address - Country:US
Practice Address - Phone:847-275-5961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7802207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX363846202Medicaid