Provider Demographics
NPI:1700857059
Name:WARD, AMANDA FAIRCLOTH (CRNA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:FAIRCLOTH
Last Name:WARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-628-6990
Mailing Address - Fax:804-628-6932
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:ANESTHESIOLOGY CRNA
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-628-6990
Practice Address - Fax:804-628-6932
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY557126367500000X
VA0024167211367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00459772OtherMEDICARE RAILROAD
R4C181Medicare ID - Type Unspecified
VAP00459772OtherMEDICARE RAILROAD