Basic Information
| Provider Information | |||||||||
| NPI: | 1508195231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMAI | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IRISH | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2742 DOW AVE | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927807242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146651600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2742 DOW AVE | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927807242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146651600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2009 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 18741 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 18741 | 01 | CA | NURSE PRACTITIONER | OTHER | 571054 | 01 | CA | CALIFORNIA REGISTERED NURSE | OTHER |