Healthcare Provider Details

I. General information

NPI: 1497868376
Provider Name (Legal Business Name): AMANDA R ROSAASEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 03/07/2023
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 E WILBUR RD # 100
THOUSAND OAKS CA
91360-5572
US

IV. Provider business mailing address

187 E WILBUR RD # 100
THOUSAND OAKS CA
91360-5572
US

V. Phone/Fax

Practice location:
  • Phone: 805-492-1015
  • Fax: 805-492-2035
Mailing address:
  • Phone: 805-492-1015
  • Fax: 805-492-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA85780
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: