Provider Demographics
NPI:1215342852
Name:MARVIN, AMANDA MAE (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAE
Last Name:MARVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MAE
Other - Last Name:PALICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5110 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2791
Mailing Address - Country:US
Mailing Address - Phone:480-295-8072
Mailing Address - Fax:
Practice Address - Street 1:5110 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2791
Practice Address - Country:US
Practice Address - Phone:480-295-8072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37073207Q00000X
AZ54116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine