Provider Demographics
NPI:1275128068
Name:SEGOVIA, AMANDA GABRIELA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GABRIELA
Last Name:SEGOVIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12051 TIERRA ESTE RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-4573
Mailing Address - Country:US
Mailing Address - Phone:915-921-6302
Mailing Address - Fax:915-219-4450
Practice Address - Street 1:12051 TIERRA ESTE RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-4573
Practice Address - Country:US
Practice Address - Phone:915-921-6302
Practice Address - Fax:915-219-4450
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50943183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist