Provider Demographics
NPI:1720745102
Name:AMIN, MARTIN NJIFUA
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:NJIFUA
Last Name:AMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 PEAKS TRL
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-1955
Mailing Address - Country:US
Mailing Address - Phone:978-893-8480
Mailing Address - Fax:
Practice Address - Street 1:224 PEAKS TRL
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30102-1955
Practice Address - Country:US
Practice Address - Phone:978-893-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-20
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN297188163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH009788938480Medicaid