Provider Demographics
NPI:1932899598
Name:FENDER, AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FENDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 GUSDORF RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6282
Mailing Address - Country:US
Mailing Address - Phone:575-737-3415
Mailing Address - Fax:
Practice Address - Street 1:700 N HENSON ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:CO
Practice Address - Zip Code:81235-5134
Practice Address - Country:US
Practice Address - Phone:970-944-2331
Practice Address - Fax:970-944-2320
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2024-0101363AM0700X
COPA.0009156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical