Provider Demographics
NPI:1033104815
Name:ANDERSON, MARTHA (PA)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9100 WESCOTT DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-4677
Mailing Address - Country:US
Mailing Address - Phone:908-237-6919
Mailing Address - Fax:
Practice Address - Street 1:9100 WESCOTT DR
Practice Address - Street 2:SUITE 103
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4677
Practice Address - Country:US
Practice Address - Phone:908-237-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00025600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ021026Medicare ID - Type Unspecified
NJS65926Medicare UPIN