Provider Demographics
NPI:1558949933
Name:THOMASON, AMANDA GRACE BORTLE (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE BORTLE
Last Name:THOMASON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 WALNUT GROVE RD STE 417
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2124
Mailing Address - Country:US
Mailing Address - Phone:901-226-1358
Mailing Address - Fax:
Practice Address - Street 1:6401 POPLAR AVE STE 610
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4806
Practice Address - Country:US
Practice Address - Phone:901-227-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program