Provider Demographics
NPI:1558701631
Name:MARTIN, AMANDA CENAC (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:CENAC
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:CLAIR
Other - Last Name:CENAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE S350
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-349-6350
Mailing Address - Fax:504-934-8701
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE S350
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6350
Practice Address - Fax:504-934-8701
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2370316Medicaid
MS00287527Medicaid
LA342688YH3UMedicare PIN