Provider Demographics
NPI:1245225473
Name:TABUENA, AMELIA L A (MD)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:L A
Last Name:TABUENA
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 1:701 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-2003
Mailing Address - Country:US
Mailing Address - Phone:215-830-9568
Mailing Address - Fax:215-830-9579
Practice Address - Street 1:701 EASTON RD
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-2003
Practice Address - Country:US
Practice Address - Phone:215-830-9568
Practice Address - Fax:215-830-9579
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039601208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA011012507-001Medicaid
PA011012507-001Medicaid
184499JP8Medicare ID - Type Unspecified