Provider Demographics
NPI:1316210933
Name:MARTIN, AMANDA MARYELLEN (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARYELLEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials: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 1:24630 WASHINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:521 E ELDER ST
Practice Address - Street 2:SUITE 106
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3081
Practice Address - Country:US
Practice Address - Phone:760-723-8337
Practice Address - Fax:760-723-5476
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2014-03-31
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