Healthcare Provider Details

I. General information

NPI: 1164086633
Provider Name (Legal Business Name): AMANDA ROACH YANEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA DANIELLE ROACH MD

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 05/06/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PAN AMERICAN FREEWAY NE STE 200 FAMILY MEDICINE
ALBUQUERQUE NM
87109-3401
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-8282
  • Fax: 505-823-8275
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2022-1203
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: