Provider Demographics
NPI:1477781516
Name:MISINCO, AMANDA S (OD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:MISINCO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2245
Mailing Address - Country:US
Mailing Address - Phone:480-478-9563
Mailing Address - Fax:
Practice Address - Street 1:4510 E CACTUS RD
Practice Address - Street 2:JCPENNEY OPTICAL
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7702
Practice Address - Country:US
Practice Address - Phone:602-996-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist