Provider Demographics
NPI:1073746632
Name:TAM, AMANDA LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LOUISE
Last Name:TAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LOUISE
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1920 CORPORATE DR STE 208
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-6286
Mailing Address - Country:US
Mailing Address - Phone:512-878-6330
Mailing Address - Fax:512-878-6941
Practice Address - Street 1:1920 CORPORATE DR STE 208
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-6286
Practice Address - Country:US
Practice Address - Phone:512-878-6330
Practice Address - Fax:512-878-6941
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002020363A00000X
TXPA12794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX408946801Medicaid
1A2046OtherMEDICARE
P02466967OtherRR MEDICARE