Healthcare Provider Details

I. General information

NPI: 1689861221
Provider Name (Legal Business Name): AMANDA M QUEEN P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2007
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

1919 E THOMAS RD BUILDING 2108, SUITE 101
PHOENIX AZ
85016-7710
US

V. Phone/Fax

Practice location:
  • Phone: 602-546-1900
  • Fax: 602-546-1918
Mailing address:
  • Phone: 602-512-8030
  • Fax: 602-512-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3692
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: