Basic Information
| Provider Information | |||||||||
| NPI: | 1548461080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUGGMAN | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8625 E VIA DE SERENO | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852583935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145583568 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5201 HARRY HINES BLVD | ||||||||
| Address2: | HOUSE STAFF & GME | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145908058 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 06/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 51706 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M7882 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | BP1-0023737 | 01 | INSTITUTIONAL PERMIT | OTHER |