Healthcare Provider Details

I. General information

NPI: 1760758064
Provider Name (Legal Business Name): AMANDA FRANCES DERYLO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA FRANCES EMERY M.D.

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 06/16/2025
Certification Date: 10/26/2023
Deactivation Date: 03/20/2025
Reactivation Date: 06/16/2025

III. Provider practice location address

3001 BROADMOOR BLVD NE
RIO RANCHO NM
87144-2100
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-7000
  • Fax:
Mailing address:
  • Phone: 505-272-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number66825
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2017-0803
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: