Healthcare Provider Details

I. General information

NPI: 1932530698
Provider Name (Legal Business Name): AMANDA LEN MARTIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARTIN GAGNON

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 09/04/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VALLEY ANESTHESIA 4504 STARKEY RD
ROANOKE VA
24018
US

IV. Provider business mailing address

7893 CEDAR EDGE RD
ROANOKE VA
24018
US

V. Phone/Fax

Practice location:
  • Phone: 540-345-3556
  • Fax:
Mailing address:
  • Phone: 540-521-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024171450
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: