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General NPI Number Information
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NPI Number | 1083024277
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Entity Type | Individual
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Provider Name | AMANDA BORN BERNATH M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/28/2014
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 100 COUNTY ROAD B
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City | SHAWANO
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State | WI
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Zip | 54166-7072
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Country | US
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Telephone | 715-524-2161
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Fax | 715-526-3461
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Provider Business Mailing Address
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Address Line | 122 E COLLEGE AVE
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City | APPLETON
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State | WI
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Zip | 54911-5794
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Country | US
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Telephone | 920-996-3264
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Fax | 920-830-5970
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 65840
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License Number State | WI
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