Healthcare Provider Details

I. General information

NPI: 1134319700
Provider Name (Legal Business Name): AMANDA R DEROSA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 E OLD CANYON CT
FLAGSTAFF AZ
86001-6006
US

IV. Provider business mailing address

1072 E OLD CANYON CT
FLAGSTAFF AZ
86001-6006
US

V. Phone/Fax

Practice location:
  • Phone: 928-220-7504
  • Fax:
Mailing address:
  • Phone: 928-607-4037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7738
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number7738
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number7738
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: