Provider Demographics
NPI:1568738730
Name:SUSTAITA, AMANDA M (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:SUSTAITA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:12221 MERIT DR
Mailing Address - Street 2:STE. 1600
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2202
Mailing Address - Country:US
Mailing Address - Phone:214-217-1935
Mailing Address - Fax:214-217-1956
Practice Address - Street 1:12221 MERIT DR
Practice Address - Street 2:STE. 1600
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2202
Practice Address - Country:US
Practice Address - Phone:214-217-1935
Practice Address - Fax:214-217-1956
Is Sole Proprietor?:No
Enumeration Date:2012-03-31
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX730895363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX299980701Medicaid
TX299980702Medicaid
TXTXB151899Medicare PIN
TX299980702Medicaid