Provider Demographics
NPI:1932530698
Name:MARTIN, AMANDA LEN (CRNA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARTIN
Other - Last Name:GAGNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7893 CEDAR EDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018
Mailing Address - Country:US
Mailing Address - Phone:540-521-9439
Mailing Address - Fax:
Practice Address - Street 1:VALLEY ANESTHESIA
Practice Address - Street 2:4504 STARKEY RD
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-345-3556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-06
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1367500000X
VA0024171450367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered