Provider Demographics
NPI:1881007482
Name:NOPAKUN, AMANDA (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NOPAKUN
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 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-0770
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:MCHJ-CLF-C
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-968-1340
Practice Address - Fax:253-968-2608
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE28679208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE28679Medicaid