Healthcare Provider Details

I. General information

NPI: 1740631886
Provider Name (Legal Business Name): AMANDA ROCHELLE MARIANO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W 10TH AVE FL 5
COLUMBUS OH
43210-1240
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-3196
  • Fax: 614-293-4812
Mailing address:
  • Phone: 614-293-3196
  • Fax: 614-293-4812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008501RX
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: