Provider Demographics
NPI:1730202623
Name:JOHNSON, AMANDA MOORE (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MOORE
Last Name:JOHNSON
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 1:2710 HARNEY ST
Mailing Address - Street 2:STE 100
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-0001
Mailing Address - Country:US
Mailing Address - Phone:307-771-2884
Mailing Address - Fax:
Practice Address - Street 1:2710 HARNEY ST
Practice Address - Street 2:STE 100
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-0001
Practice Address - Country:US
Practice Address - Phone:307-742-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241086207V00000X
ORMD28544207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology