Basic Information
| Provider Information | |||||||||
| NPI: | 1295362010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURAZO | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | RENEA | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SKOPHAMMER | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | RENEA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1408 CARDIFF LN | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272659105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147136848 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 930 CHESTNUT RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265052807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042935323 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2020 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.