Provider Demographics
NPI:1659785103
Name:SMITH, AMANDA (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SMITH
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 1:4320 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5925
Mailing Address - Country:US
Mailing Address - Phone:907-729-3300
Mailing Address - Fax:907-729-8997
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-729-3300
Practice Address - Fax:907-729-8997
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077946A207Q00000X
IN11017833A390200000X
AK163991207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program