Provider Demographics
NPI:1669548673
Name:SELF, AMANDA R (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:R
Last Name:SELF
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 1:3944 HIGHWAY 175
Mailing Address - Street 2:
Mailing Address - City:FRIERSON
Mailing Address - State:LA
Mailing Address - Zip Code:71027-2159
Mailing Address - Country:US
Mailing Address - Phone:318-402-0604
Mailing Address - Fax:
Practice Address - Street 1:7TH COMM BN HQ CO BAS
Practice Address - Street 2:UNIT 35610
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96606-5610
Practice Address - Country:US
Practice Address - Phone:318-402-0604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062935A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice