Provider Demographics
NPI:1013598499
Name:MASCARENAS, AMANDA MARIE (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:MASCARENAS
Suffix:
Gender:F
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-7828
Mailing Address - Country:US
Mailing Address - Phone:540-220-8171
Mailing Address - Fax:
Practice Address - Street 1:262 CRESTWOOD LN
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-7828
Practice Address - Country:US
Practice Address - Phone:540-220-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-18
Last Update Date:2021-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-41492083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine