Provider Demographics
NPI:1134319700
Name:DEROSA, AMANDA R (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:DEROSA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 E OLD CANYON CT
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-6006
Mailing Address - Country:US
Mailing Address - Phone:928-607-4037
Mailing Address - Fax:
Practice Address - Street 1:1072 E OLD CANYON CT
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6006
Practice Address - Country:US
Practice Address - Phone:928-220-7504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ77382251X0800X, 225100000X
2251X0800X
77382251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00432914OtherRAILROAD MEDICARE
AZP00432914OtherRAILROAD MEDICARE