Healthcare Provider Details

I. General information

NPI: 1346245594
Provider Name (Legal Business Name): AMANDA J STORY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 JEFFERSON LN NE
ALBUQUERQUE NM
87109-2127
US

IV. Provider business mailing address

4650 JEFFERSON LN NE
ALBUQUERQUE NM
87109-2127
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7900
  • Fax: 505-727-7942
Mailing address:
  • Phone: 505-727-7900
  • Fax: 505-727-7942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number89-310
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: