Provider Demographics
NPI:1407205354
Name:MANSOURI, AMANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:MANSOURI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:LEILAH
Other - Last Name:DEBUHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4701 MONTEREY OAKS BLVD APT 325
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4701 MONTEREY OAKS BLVD APT 325
Practice Address - Street 2:NOT A PHYSICAL LOCATION
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1083
Practice Address - Country:US
Practice Address - Phone:865-274-1074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN62255208D00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No376J00000XNursing Service Related ProvidersHomemaker