Healthcare Provider Details

I. General information

NPI: 1427329077
Provider Name (Legal Business Name): AMANDA MORGAN FREEMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST 2ND FL AREA 3
ESPANOLA NM
87532-2724
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-367-0340
  • Fax: 505-367-0346
Mailing address:
  • Phone: 505-367-0340
  • Fax: 505-367-0346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2024-0048
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: