Healthcare Provider Details

I. General information

NPI: 1457367179
Provider Name (Legal Business Name): AMANDA TAGLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7215 55TH STREET
SACRAMENTO CA
95823-2601
US

IV. Provider business mailing address

625 FAIR OAKS AVE STE 270
SOUTH PASADENA CA
91030-5801
US

V. Phone/Fax

Practice location:
  • Phone: 916-399-1100
  • Fax: 877-860-2397
Mailing address:
  • Phone: 626-346-2455
  • Fax: 626-639-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA60188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: