Healthcare Provider Details

I. General information

NPI: 1104192525
Provider Name (Legal Business Name): AMANDA RAPP M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BETHANY HOME RD
PHOENIX AZ
85015-2443
US

IV. Provider business mailing address

2000 W BETHANY HOME RD # 200
PHOENIX AZ
85015-2443
US

V. Phone/Fax

Practice location:
  • Phone: 602-246-5658
  • Fax:
Mailing address:
  • Phone: 602-246-5525
  • Fax: 602-433-6686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR73186
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: