Healthcare Provider Details

I. General information

NPI: 1689404006
Provider Name (Legal Business Name): AMANDA MARTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S STATE ST
DOVER DE
19901-3530
US

IV. Provider business mailing address

146 ALINDA LN
STROUDSBURG PA
18360-7635
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-4700
  • Fax:
Mailing address:
  • Phone: 570-460-9179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: