Healthcare Provider Details

I. General information

NPI: 1225485741
Provider Name (Legal Business Name): AMANDA MOYER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 STANTON L YOUNG BLVD STE 524
OKLAHOMA CITY OK
73104-5022
US

IV. Provider business mailing address

1122 NE 13TH ST # 274
OKLAHOMA CITY OK
73117-1039
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5955
  • Fax: 405-271-8852
Mailing address:
  • Phone: 405-271-5955
  • Fax: 405-271-8852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32277
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32277
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: