Healthcare Provider Details

I. General information

NPI: 1700111887
Provider Name (Legal Business Name): AMANDA TENCZA WHITAKER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4860 Y ST STE 3800
SACRAMENTO CA
95817-2307
US

IV. Provider business mailing address

4860 Y ST STE 3800
SACRAMENTO CA
95817-2307
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-7353
  • Fax: 916-734-7904
Mailing address:
  • Phone: 916-734-7353
  • Fax: 916-734-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License NumberA114996
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number35127570
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: