Basic Information
| Provider Information | |||||||||
| NPI: | 1588980700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331814 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3555 S VAL VISTA DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852977323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029330777 | ||||||||
| FaxNumber: | 6029330755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
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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 | 208M00000X | 47681 | AZ | Y | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 804216 | 05 | AZ | MEDICAID |