Healthcare Provider Details

I. General information

NPI: 1356906168
Provider Name (Legal Business Name): AMANDA G MARIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA G KOCHASIC

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date: 06/09/2020
Reactivation Date: 07/22/2020

III. Provider practice location address

2188 SANDY DR
STATE COLLEGE PA
16803-2288
US

IV. Provider business mailing address

155 WELLNESS WAY
STATE COLLEGE PA
16803-6702
US

V. Phone/Fax

Practice location:
  • Phone: 814-237-6600
  • Fax: 814-237-5383
Mailing address:
  • Phone: 814-231-7100
  • Fax: 814-238-0790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA004795
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA060569
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14830
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: