Provider Demographics
NPI:1205009362
Name:BONAZZI, AMANDA MARIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:BONAZZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:MALEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6500 NORTH MOPAC
Mailing Address - Street 2:BUILDING 3 SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-458-8400
Mailing Address - Fax:512-458-8593
Practice Address - Street 1:170 DEEPWOOD DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4944
Practice Address - Country:US
Practice Address - Phone:512-458-8400
Practice Address - Fax:512-458-8593
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX721093364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F8066Medicare PIN
TX8K7144Medicare PIN