Provider Demographics
NPI:1790821908
Name:ANDRADA, MARTA (CNM)
Entity type:Individual
Prefix:
First Name:MARTA
Middle Name:
Last Name:ANDRADA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2100
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-2100
Mailing Address - Country:US
Mailing Address - Phone:843-488-6363
Mailing Address - Fax:843-248-3145
Practice Address - Street 1:1608 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3572
Practice Address - Country:US
Practice Address - Phone:843-248-4700
Practice Address - Fax:843-248-3145
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO07889600363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMW0244Medicaid
NJ311866Medicare ID - Type Unspecified