=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932899598
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA FENDER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2023
-----------------------------------------------------
Last Update Date | 06/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 N HENSON ST
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81235-5134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-944-2331
-----------------------------------------------------
Fax | 970-944-2320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1329 GUSDORF RD
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-6282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-737-3415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA2024-0101
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA.0009156
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------