Provider Demographics
NPI:1164468161
Name:CANOVA, AMANDA DERRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:DERRICK
Last Name:CANOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 WILLOW GROVE ST
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-1732
Mailing Address - Country:US
Mailing Address - Phone:908-852-7770
Mailing Address - Fax:908-852-7755
Practice Address - Street 1:653 WILLOW GROVE ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-1732
Practice Address - Country:US
Practice Address - Phone:908-852-7770
Practice Address - Fax:908-852-7755
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA71710207V00000X
PAMD441088207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0027553Medicaid
NJ080914MWNMedicare ID - Type Unspecified
NJ0027553Medicaid