Provider Demographics
NPI:1871737973
Name:HALL, AMANDA KAYE (DO)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KAYE
Last Name:HALL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3525 E LOUISE DR STE 195
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6303
Mailing Address - Country:US
Mailing Address - Phone:208-846-8335
Mailing Address - Fax:208-846-8336
Practice Address - Street 1:3525 E LOUISE DR STE 195
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-846-8335
Practice Address - Fax:208-846-8336
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7771762-1204207R00000X
IDO-0858207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20007232Medicare PIN