Provider Demographics
NPI:1073212494
Name:PEREZ, AMANDA (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PEREZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 FARENHOLT AVE
Mailing Address - Street 2:UR 1 BUILDING
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:671-647-0110
Mailing Address - Fax:
Practice Address - Street 1:224 FARENHOLT AVE
Practice Address - Street 2:UR 1 BUILDING
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-647-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP161372340225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant