Basic Information
| Provider Information | |||||||||
| NPI: | 1952761017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6171 EXECUTIVE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208523901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028886731 | ||||||||
| FaxNumber: | 2028515739 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159555000 | ||||||||
| FaxNumber: | 2159231089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 26NJ00564400 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | SP016128 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 103243391 0001 | 05 | PA | MEDICAID |