Basic Information
| Provider Information | |||||||||
| NPI: | 1790047355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUNYAN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUNYAN | ||||||||
| OtherFirstName: | MANDY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 PLEASANT AVE. | ||||||||
| Address2: | ST. JOSEPH'S AREA HEALTH SERVICES | ||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182375496 | ||||||||
| FaxNumber: | 2182375702 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 PLEASANT AVE. | ||||||||
| Address2: | ST. JOSEPH'S AREA HEALTH SERVICES | ||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182375496 | ||||||||
| FaxNumber: | 2182375702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2012 | ||||||||
| LastUpdateDate: | 06/11/2012 | ||||||||
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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 | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.