Provider Demographics
NPI:1245437979
Name:PRINCE, AMANDA COMBS (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:COMBS
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KAYE
Other - Last Name:COMBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2500 FOUNDATION WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-9000
Mailing Address - Country:US
Mailing Address - Phone:304-264-9202
Mailing Address - Fax:304-264-9042
Practice Address - Street 1:5047 GERRARDSTOWN RD STE 2B
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-3951
Practice Address - Country:US
Practice Address - Phone:304-821-1444
Practice Address - Fax:304-821-1450
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDFC1277169207Q00000X
WV23193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810027357Medicaid
WVWV4074B987OtherMEDICARE PTAN