Provider Demographics
NPI:1366655839
Name:TRUCKSESS, AMANDA B (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:TRUCKSESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11240 WAPLES MILL RD 403
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6078
Mailing Address - Country:US
Mailing Address - Phone:703-383-6424
Mailing Address - Fax:703-810-5369
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:SUITE 400
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-810-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116016644390200000X
VA0101243539208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
538695Medicare PIN
C10465Medicare PIN
P00640299Medicare PIN
CA2348Medicare PIN
MC11328Medicare PIN
126668YR3Medicare PIN