Basic Information
Provider Information | |||||||||
NPI: | 1992098123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FANTRY | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 ASYLUM AVE STE 2126 | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061051718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8607286740 | ||||||||
FaxNumber: | 8605471554 | ||||||||
Practice Location | |||||||||
Address1: | 1000 ASYLUM AVE STE 2126 | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 06105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8607286740 | ||||||||
FaxNumber: | 8605471554 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2011 | ||||||||
LastUpdateDate: | 05/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MD15395 | RI | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0004X | 61342 | CT | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207X00000X | 61342 | CT | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.