Provider Demographics
NPI:1255805727
Name:AGBANNAWAG, AMANDA MARYAM (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARYAM
Last Name:AGBANNAWAG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:DORRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:3988 E FORT LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1010
Mailing Address - Country:US
Mailing Address - Phone:520-488-5291
Mailing Address - Fax:520-689-6810
Practice Address - Street 1:3988 E FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1010
Practice Address - Country:US
Practice Address - Phone:520-488-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-30412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ568098Medicaid