Healthcare Provider Details

I. General information

NPI: 1427673797
Provider Name (Legal Business Name): AMANDA ANDERSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

997 SAINT SEBASTIAN WAY # EG2003
AUGUSTA GA
30912-2613
US

IV. Provider business mailing address

997 SAINT SEBASTIAN WAY # EG2003
AUGUSTA GA
30912-2613
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-6699
  • Fax: 706-721-3593
Mailing address:
  • Phone: 706-721-6699
  • Fax: 706-721-3593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11971
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: