Provider Demographics
NPI:1659889004
Name:BERG, AMANDA CATHERINE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CATHERINE
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10370 N LA CANADA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85737-7270
Mailing Address - Country:US
Mailing Address - Phone:520-544-4100
Mailing Address - Fax:
Practice Address - Street 1:10370 N LA CANADA DR STE 150
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85737-7270
Practice Address - Country:US
Practice Address - Phone:520-544-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant