Provider Demographics
NPI:1043553217
Name:COLYER, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:COLYER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844088
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4088
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:
Practice Address - Street 1:2700 FARMINGTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4559
Practice Address - Country:US
Practice Address - Phone:505-609-6380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1003X, 390200000X
NMPA2023-0287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program