Provider Demographics
NPI:1184750572
Name:ANDERSON, MARTHA JANE (ATC)
Entity type:Individual
Prefix:MISS
First Name:MARTHA
Middle Name:JANE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:800 GOLDEN DR
Mailing Address - Street 2:APT C17
Mailing Address - City:BLANDON
Mailing Address - State:PA
Mailing Address - Zip Code:19510-9446
Mailing Address - Country:US
Mailing Address - Phone:610-944-1611
Mailing Address - Fax:
Practice Address - Street 1:KUTZTOWN UNIVERSITY SPORTS MEDICINE
Practice Address - Street 2:KUTZTOWN UNIVERSITY
Practice Address - City:KUTZTOWN
Practice Address - State:PA
Practice Address - Zip Code:19530-9446
Practice Address - Country:US
Practice Address - Phone:610-683-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART001363A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PART001363AOtherSTATE LICENSE #