Basic Information
| Provider Information | |||||||||
| NPI: | 1407385560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AUSTIN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7800 NW 85TH TER STE 200 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731323385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059727239 | ||||||||
| FaxNumber: | 4057531863 | ||||||||
| Practice Location | |||||||||
| Address1: | 5224 E I 240 SERVICE RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731352607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056083800 | ||||||||
| FaxNumber: | 4056286791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2017 | ||||||||
| LastUpdateDate: | 07/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 89429 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | L100016517 | 01 | OK | DRIVER'S LICENSE | OTHER |