Healthcare Provider Details

I. General information

NPI: 1073794269
Provider Name (Legal Business Name): AMANDA LEE TAGLIOLI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 MONTGOMERY STREET
CUSTER SD
57730-1304
US

IV. Provider business mailing address

317 APPLE DR
STEAMBOAT SPRINGS CO
80487-3074
US

V. Phone/Fax

Practice location:
  • Phone: 605-673-4150
  • Fax: 605-673-3917
Mailing address:
  • Phone: 970-461-6140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0513
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: