Basic Information
| Provider Information | |||||||||
| NPI: | 1407203599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARLENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1209 KATHILEEN WAY | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949521816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499330776 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100A DRAKES LANDING RD STE 225 | ||||||||
| Address2: | |||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949043119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154617800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2016 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 20A18165 | CA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | P32561 | MD | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | P32561 | 01 | MD | STATE LICENSE NUMBER | OTHER |