Provider Demographics
NPI:1003278300
Name:FAWSON, AMANDA N (IDMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:N
Last Name:FAWSON
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 GRANT AVE
Mailing Address - Street 2:APT 241
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1462
Mailing Address - Country:US
Mailing Address - Phone:435-840-4113
Mailing Address - Fax:
Practice Address - Street 1:2155 GRANT AVE
Practice Address - Street 2:APT 241
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1462
Practice Address - Country:US
Practice Address - Phone:435-840-4113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians