Provider Demographics
NPI:1669853628
Name:MARINOVA, AMANDA MICHEL (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHEL
Last Name:MARINOVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHEL
Other - Last Name:VIERECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:919 N FRONT ST APT G
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-1715
Mailing Address - Country:US
Mailing Address - Phone:856-889-8816
Mailing Address - Fax:
Practice Address - Street 1:919 N FRONT ST APT G
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-1715
Practice Address - Country:US
Practice Address - Phone:856-889-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00369500363AM0700X
PAMA057653363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical