Basic Information
| Provider Information | |||||||||
| NPI: | 1881685303 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DELIGTISCH | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | MSC10 5620 1 UNIVERSITY OF NM | ||||||||
| Address2: | THE UNIVERSITY OF NEW MEXICO, DEPT OF NEUROLOGY | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723160 | ||||||||
| FaxNumber: | 5052729427 | ||||||||
| Practice Location | |||||||||
| Address1: | MSC10 5620 1 UNIVERSITY OF NM | ||||||||
| Address2: | THE UNIVERSITY OF NEW MEXICO, DEPT OF NEUROLOGY | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723160 | ||||||||
| FaxNumber: | 5052729427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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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 | 2084N0400X | MD2006-0534 | NM | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 74537547 | 05 | NM | MEDICAID |