Provider Demographics
NPI:1316210933
Name:MARTIN, AMANDA MARYELLEN (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARYELLEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARYELLEN
Other - Last Name:DEKOKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23100 EUCALYPTUS AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5439
Mailing Address - Country:US
Mailing Address - Phone:951-379-1500
Mailing Address - Fax:951-379-1501
Practice Address - Street 1:32605 TEMECULA PKWY STE 103
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-6838
Practice Address - Country:US
Practice Address - Phone:951-331-3660
Practice Address - Fax:951-331-3661
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 38573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT385730OtherBLUE SHIELD PIN
CA12369967OtherCAQH PROVIDER ID
CAGE201YMedicare PIN
CAGE201ZMedicare PIN