Healthcare Provider Details

I. General information

NPI: 1417254301
Provider Name (Legal Business Name): AMANDA MARTIN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15625 WOODLAND POINT RD
NEWBURG MD
20664-6304
US

IV. Provider business mailing address

15625 WOODLAND POINT RD
NEWBURG MD
20664-6304
US

V. Phone/Fax

Practice location:
  • Phone: 240-210-4075
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA3594
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: