Provider Demographics
NPI:1992212708
Name:IMBODEN, MARTENE JACQUELINE (PAC)
Entity Type:Individual
Prefix:
First Name:MARTENE
Middle Name:JACQUELINE
Last Name:IMBODEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 OSTRUM ST STE 603
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1184
Mailing Address - Country:US
Mailing Address - Phone:484-526-3990
Mailing Address - Fax:610-868-2915
Practice Address - Street 1:701 OSTRUM ST STE 603
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1184
Practice Address - Country:US
Practice Address - Phone:484-526-3990
Practice Address - Fax:610-868-2915
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059556363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical