=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730519091
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA MARTS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2013
-----------------------------------------------------
Last Update Date | 12/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 MAIN ST STE 201
-----------------------------------------------------
City | REISTERSTOWN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-526-3053
-----------------------------------------------------
Fax | 410-584-1872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 FAIRMOUNT AVE STE 400
-----------------------------------------------------
City | TOWSON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21286-8518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-526-3053
-----------------------------------------------------
Fax | 410-584-1872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | C0005273
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------