Provider Demographics
NPI:1326514159
Name:POWERS, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:POWERS
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 1:45 TOLL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MT
Mailing Address - Zip Code:59759-8636
Mailing Address - Country:US
Mailing Address - Phone:406-533-8491
Mailing Address - Fax:
Practice Address - Street 1:3341 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-3543
Practice Address - Country:US
Practice Address - Phone:406-533-8491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT45-3581651Medicaid